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SURGICAL 


APPLIED  ANATOMY 


FREDERICK 


TREVES, 


F.R.C.S. 


ASSISTANT     SURGEON     TO,    AND    SENIOR     DEMONSTRATOR     OF     ANATOMY     AT, 

THE    LONDON    HOSPITAL;    EXAMINER   IN   ANATOMY  AT   THE    UNIVERSITY 

OP     ABERDEEN  ;     WILSON     PROFESSOR     OP     PATHOLOGY,     ROYAL 

COLLEGE   OF   SURGEONS   OF   ENGLAND,    1£81. 


ILLUSTRATED   WITH  61  KNGRAVINGS. 


PHILADELPHIA  : 

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1894 


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WILLIAM    KNIGHT    TBEVES,     F.E.C.S., 

SURGEON    TO     THE     NATIONAL      HOSPITAL    FOE     SCROFULA, 


PBEFACE   TO  THE   FIEST  EDITION. 

APPLIED  ANATOMY  has,  I  imagine,  a  twofold  function. 
On  the  one  hand  it  -serves  to  gite  a  precise  basis  to 
those  incidents  and  procedures  in  practice  that  more 
especially  involve  anatomical  knowledge ;  on  the 
other  hand  it  endues  the  dull  items  of  that  knowledge 
with  meaning  and  interest  by  the  aid  of  illustrations 
drawn  from  common  medical  and  surgical  experience. 
In  this  latter  aspect  it  bears  somewhat  the  same 
relation  to  Systematic  Anatomy  that  a  series  of  ex- 
periments in  Physics  bears  to  a  treatise  dealing  with 
the  bare  data  of  that  science. 

The  student  of  Human  Anatomy  has  often  a 
nebulous  notion  that  what  he  is  learning  will  some- 
time prove  of  service  to  him ;  and  may  be  conscious 
also  that  the  study  is  a  valuable,  if  somewhat  unex- 
citing, mental  exercise.  Beyond  these  impressions  he 
must  regard  his  efforts  as  concerned  merely  in  the 
accumulation  of  a  number  of  hard  unassim liable  facts. 


24813 


viii  SURGICAL  APPLIED  ANATOMY. 

It  should  be  one  object  of  Applied  Anatomy  to  invest 
these  facts  with  the  interest  derived  from  an  associa- 
tion with  the  circumstances  of  daily  life ;  it  should 
make  the  dry  bones  live. 

It  must  be  owned  also  that  all  details  in  Anatomy 
have  not  the  same  practical  value,  and  that  the  memory 
of  many  of  them  may  fade  without  loss  to  the  compe- 
tency of  the  practitioner  in  medicine  or  surgery.  It 
should  be  one  other  object,  therefore,  of  a  book, 
having  such  a  purpose  as  the  present,  to  assist  the 
student  in  judging  of  the  comparative  value  of  the 
matter  he  has  learnt ;  and  should  help  him,  when 
his  recollection  of  anatomical  facts  grows  dim,  to 
encourage  the  survival  of  the  fittest. 

In  writing  this  manual  I  have  endeavoured,  so 
far  as  the  space  at  my  command  would  permit,  to 
carry  out  the  objects  above  described ;  and  while  I 
believe  that  the  chief  matters  usually  dealt  with  in 
works  on  Surgical  Anatomy  have  not  been  neglected, 
I  have  nevertheless  tried  to  make  the  principle  of  the 
book  the  principle  that  underlies  Mr.  Hilton's  familiar 
lectures  on  "Rest  and  Pain." 

I  have  assumed  that  the  reader  has  some  know- 
ledge of  Human  Anatomy,  and  have  not  entered, 
except  in  a  few  instances,  into  any  detailed  anatomical 


PREFACE,  ix 

descriptions.  The  bare  accounts,  for  example,  of  tin 
regions  concerned  in  Hernia  I  have  left  to  the  syste- 
matic treatises,  and  have  dealt  only  with  the  bearings 
of  the  anatomy  of  the  parts  upon  the  circumstances  of 
practice.  The  limits  of  space  have  compelled  me  to 
omit  all  those  parts  of  the  "  Surgery  of  the  Arteries  " 
that  deal  with  ligature,  collateral  circulation,  abnor- 
malities, and  the  like.  This  omission  I  do  not  regret, 
since  those  subjects  are  fully  treated  not  only  in 
works  on  operative  surgery  but  also  in  the  manuals 
of  general  anatomy. 

The  book  is  intended  mainly  for  the  use  of 
students  preparing  for  their  final  examination  in 
surgery.  I  hope,  however,  that  it  will  be  of  use  also 
to  practitioners  whose  memory  of  their  dissecting 
room  work  is  growing  a  little  gray,  and  who  would 
wish  to  recall  such  anatomical  matters  as  have  the 
most  direct  bearing  upon  the  details  of  practice. 
Moreover,  it  is  possible  that  junior  students  may  find 
some  interest  in  the  volume,  and  may  have  their 
studies  rendered  more  intelligent,  by  learning  how 
anatomy  is  concerned  in  actual  dealings  with  disease. 


Sept.,  1883. 


PREFACE  TO  THE  PEESENT  EDITION. 


IN  the  present  edition  the  work  has  been  again  care- 
fully revised  throughout ;  certain  sections  have  been 
re-written,  and  much  new  matter  has  been  added. 
Every  effort  has  been  made  to  bring  each  chapter  of 
the  book  well  up  to  date.  Two  new  woodcuts  have 
been  inserted  in  the  place  of  old  ones.  These  have 
been  derived  from  my  "  Manual  of  Operative 
Surgery." 

F.  T. 

6,  Wimpule  Street,  W., 
March,  1S92. 


CONTENTS. 


PART  I.-THE    HEAD    AND    NECK. 

CHAPTER  PAGE 

L— THE  SCALP 1 

IL— THE  BONY  VAULT  OF  THE  CRANIUM  .       .       .       .11 

in.— THE  CRANIAL  CONTENTS 29 

IV.— THE  ORBIT  AND  EYE 41 

V.— THE  EAR 69 

VI.— THE  NOSE  AND  NASAL  CAVITIES 81 

VII.— THE  FACE 97 

VIII.— THE  MOUTH,  TONGUE,  PALATE,  AND  PHARYNX     .  118 

IX.— THE  NECK   .                                                             .  137 


PART   II. 
X.— THE  THORAX       .......  .170 


PART   III.-THE    UPPER   EXTREMITY. 

XL— THE  REGION  OF  THE  SHOULDER 186 

XIL-TiiK  ARM .226 


xii  SURGICAL  APPLIED  ANATOMY. 

CHAPTER  PAGE 

XIII.— THE  REGION  OF  THE  ELBOW 234 

XIV.— THE  FORE-ARM 251 

XV.— THE  WRIST  AND  HAND   .  .    259 


PART   IV.— THE    ABDOMEN    AXD    PELVIS. 

XVI. —THE  ABDOMEN 287 

XVII.— THE  ABDOMINAL  VISCERA 322 

XVIII.— THE  PELVIS  AND  PERINEUM  .  .  372 


PART    V.— THE   LOWER   EXTREMITY. 

XIX.— THE  REGION  OF  THE  HIP 421 

XX.— THE  THIGH  . 461 

XXL— THE  REGION  OF  THE  KNEE 4.68 

XXH.-THE  LEG      .  494 

XXLTL--THE  ANKLE  AND  FOOT 505 


PART   IV. 

XXIV.— THE  SPINE 511 

INDEX     ....  561 


SURGICAL  APPLIED  ANATOMY. 


}i)art  I. 

THE    HEAD    AND    NECK. 


CHAPTER   I. 

THE    SCALP. 

THE  soft  parts  covering  the  vault  of  the 
skull  may  be  divided  into  five  layers  :  (1)  the  skin, 
(2)  the  subcutaneous  fatty  tissue,  (3)  the  occipito- 
frontalis  muscle  and  its  aponeurosis,  (4)  the  sub- 
aponeurotic  connective  tissue,  and  (5)  the  pericranium. 
It  is  convenient  to  consider  the  term  "  scalp "  as 
limited  to  the  structure  formed  by  the  union  of  the 
first  three  layers  above  named  (Fig.  1). 

The  skin  of  the  scalp  is  thicker  than  it  is  in  any 
other  part  of  the  body.  It  is  in  all  parts  intimately 


Fig.  1.— Diagram  of  a  Vertical  Section  of  the  Scalp. 

a.  Skin ;  6,  subcutaneous  tissue,  with  vessels ;  c,  aponeurosis  ;  d,  sub-aponeuro- 
tic  tissue ;  «,  pericranium ;  /,  bone  ;  g,  dura  mater. 

adherent,  by  means  of  the  subcutaneous  tissue,  to  the 
aponeurosis   and  muscle  beneath  it,  and,    from  this 
B— 4 


2  SURGICAL   APPLIED   ANATOMY.      ichap.  i. 

adhesion,  it  follows  that  the  skin  moves  in  all  move- 
ments of  that  muscle.  The  subcutaneous  tissue  is,  like 
a  similar  tissue  in  the  palm,  admirably  constructed  to 
resist  pressure,  being  composed  of  a  multitude  of  fibrous 
bands  enclosing  fat  lobules  in  more  or  less  isolated 
spaces.  The  density  of  the  scalp  is  such,  that  in 
surface  inflammations,  such  as  cutaneous  erysipelas,  it 
is  unable  to  present  (except  in  a  very  slight  degree) 
two  conspicuous  features  of  such  inflammations,  viz., 
redness  and  swelling.  The  skin  is  provided  with  a 
great  number  of  sebaceous  glands,  which  may  develop 
into  cystic  tumours  or  wens,  such  cysts  being  more 
common  upon  the  scalp  than  in  any  other  part  of  the 
body.  Being  skin  growths,  these  cysts,  even  when 
large,  remain,  except  in  rare  instances,  entirely  out- 
side the  aponeurosis,  and  can  therefore  be  removed 
without  risk  of  opening  up  the  area  of  loose  con- 
nective tissue  between  the  aponeurosis  and  the  peri- 
cranium. 

There  being  no  fatty  tissue  in  any  of  the  layers 
that  cover  the  bony  vault,  save  in  the  subcutaneous 
layer,  it  happens  that  in  cases  of  obesity  the  scalp 
undergoes  but  little  change,  the  fat  in  the  subcu- 
taneous tissue  being  limited  by  the  dense  fibrous 
.structures  that  enclose  it.  For  the  same  reasons  fatty 
tumours  of  the  scalp  are  very  rare.  The  attachment 
of  the  hairs  collectively  to  the  scalp  is  so  strong  that 
there  are  many  cases  where  the  entire  weight  of  the 
body  has  been  supported  by  the  hair  of  the  scalp. 
Ague w  records  the  case  of  a  woman  whose  hair 
became  entangled  in  the  revolving  shaft  of  a  machine. 
The  hair  did  not  give  way,  but  the  entire  scalp  was 
torn  off  from  the  skull.  The  patient  recovered.  I 
have  seen  a  precisely  similar  case  in  a  girl  aged  13. 

The  dangerous  area  of  the  scalp.— Between 
the  aponeurosis  and  the  pericranium  is  an  extensive 
layer  of  loose  connective  tissue,  that  may,  for  reasons 


chap,  i.)  THE  SCALP.  3 

to  be  presently  given,  be  fairly  called  the  dangerous 
area  of  the  scalp  (Fig.  1,  d).  The  mobility  of  the 
scalp  depends  entirely  upon  the  laxity  of  this  layer  of 
tissue.  In  extensive  scalp  wounds,  when  a  part  of 
the  scalp  is  separated  in  the  form  of  a  large  flap,  a 
flap  that  may  hang  down  and  cover  half  the  face,  it 
is  the  very  looseness  of  this  tissue  that  permits  such 
separation.  In  the  Indian  process  of  scalping,  a 
taste  that  is  becoming  one  of  the  past,  the  much- 
prized  piece  of  skin  is  torn  from  the  skull  through 
this  lax  area  of  connective  tissue,  and,  were  there  no 
such  area,  scalping  would  be  an  operation  requiring 
some  time  and  art. 

The  exposure  of  the  skull  in  a  post-mortem  exami- 
nation is  effected  by  peeling  off  the  scalp  along 
this  layer  of  loose  tissue,  and  it  is  remarkable  with 
what  ease  the  skull  can  bo  exposed  by  this  mano3uvre. 
Sutures  may  be  safely  applied  to  adjust  scalp 
wounds,  provided  they  are  not  too  long  retained. 
They  probably  include  the  aponeurosis,  and  if  long 
retained  may  act  as  setons  and  set  up  suppuration, 
which  may  find  its  way  into  the  loose  layer  beneath 
the  aponeurosis. 

Wounds  of  the  scalp  never  gape,  unless 
the  wound  has  involved  the  scalp  muscle  or  its 
aponeurosis.  When  this  structure  has  been  divided, 
the  lax  layer  beyond  permits  of  great  separation  of 
the  edges  of  even  the  simplest  wound.  In  uncompli- 
cated incised  wounds,  the  amount  of  gaping  of  the 
cut  depends  upon  the  action  of  the  occipito-frontalis 
muscle.  Those  wounds  gape  the  most  that  are  made 
across  the  muscle  itself,  and  that  are  transverse  to  the 
direction  of  its  fibres,  while  those  show  the  least 
separation  that  involve  the  aponeurosis  and  are  made 
in  an  antero-posterior  direction.  The  mobility  of  the 
scalp  is  more  marked  in  the  young  than  in  the  old. 
A.  case  recorded  by  Agnew  serves  in  a  strange  degree 


4  SURGICAL  APPLIED  ANATOMY.        ichap.  i. 

to  illustrate  this  fact  in  the  person  of  an  infant.  A 
midwife  attending  a  woman  in  labour  mistook  the 
scalp  of  the  infant  for  the  membranes,  and  gashed  it 
with  a  pair  of  scissors.  Labour  pains  came  on  and  the 
head  was  protruded  through  the  scalp  wound,  so  that 
the  whole  vault  of  the  skull  was  peeled  like  an  orange. 
The  scalp  being  firmly  stretched  over  the  hard 
cranium  beneath,  it  follows  that  contused  wounds 
often  appear  as  cleanly  cut  as  are  those  that  have 
been  made  by  an  incision.  Such  wounds  may  be 
compared  to  the  clean  cut  that  may  be  made  in  a  kid 
glove  when  it  is  tightly  stretched  over  the  knuckles, 
and  those  parts  are  sharply  rapped. 

The  scalp  is  extremely  vascular,  and  presents  there- 
fore a  great  resistance  to  sloughing  and  gangrenous 
conditions.  Large  flaps  of  a  lacerated  scalp,  even 
when  extensively  separated  and  almost  cut  off  from 
the  rest  of  the  head,  are  more  prone  to  live  than  to 
die.  A  like  flap  of  skin,  separated  from  other  parts 
of  the  surface,  would  most  probably  perish ;  but  the 
scalp  has  this  advantage,  that  the  vessels  run  practi- 
cally in  the  skin  itself,  or  are,  at  least,  in  the  tissue 
beyond  the  aponeurosis  (Fig.  1).  Thus,  when  a  scalp 
flap  is  torn  up,  it  still  carries  with  it  a  very  copious 
blood  supply.  Bleeding  from  these  wounds  is  usually 
very  free,  and  often  difficult  to  arrest.  This  depends,  not 
so  much  upon  the  number  of  vessels  in  the  part,  as 
upon  the  density  of  the  tissue  through  which  these 
vessels  run,  the  adherence  of  the  outer  arterial  wall  to 
the  scalp  structure,  and  the  inability,  therefore,  of  the 
artery  to  properly  retract  when  divided. 

For  the  same  reason  it  is  almost  impossible  to 
pick  up  an  artery  divided  in  a  scalp  wound.  The 
bleeding  is  checked  by  a  hare-lip  pin  or  by  pressure. 

In  all  parts  of  the  body  where  a  dense  bone  is 
covered  by  a  comparatively  thin  layer  of  soft  tissues, 
sloughing  of  those  tissues  is  apt  to  be  induced  by 


Chap.  T.]  THE  SCALP.  5 

long  and  severe  pressure.  The  scalp,  by  its  vascu- 
larity,  is  saved  to  a  great  extent  from  this  evil,  and  is 
much  less  liable  to  slough  than  are  the  soft  pai-ts 
covering  such  bones  as  the  condyles  of  the  humerus  or 
the  sacrum.  But  such  an  effect  is  sometimes  pro- 
duced, as  in  a  case  I  saw,  where  the  tissues  over  the 
frontal  and  occipital  regions  sloughed  from  the  con- 
tinued application  of  a  tight  bandage  put  on  to  arrest 
bleeding  from  a  frontal  wound. 

The  pericranium  is  but  slightly  adherent  to 
the  bone,  except  at  the  sutures,  where  it  is  intimately 
united.  In  lacerated  wounds  this  membrane  can  be 
readily  stripped  from  the  skull,  and  often,  in  these 
injuries,  extensive  tracts  of  bone  are  laid  bare.  The 
pericranium  differs  somewhat  in  its  functions  from  the 
periosteum  that  covers  other  bones.  If  the  periosteum 
be  removed  to  any  extent  from  a  bone,  the  part  from 
whence  it  is  removed  will  very  probably  perish,  and 
necrosis  from  deficient  blood  supply  result.  But  the 
pericranium  may  be  stripped  off  a  considerable  part  of 
the  skull  vault  without  any  necrosis,  save  perhaps  a 
little  superficial  exfoliation,  following  in  consequence. 
This  is  explained  by  the  fact  that  the  cranial  bones 
derive  their  blood  supply  mainly  from  the  dura  mater, 
and  are  therefore  to  a  considerable  extent  independent 
of  the  pericranium.  A  like  independence  cannot  be 
claimed  for  the  periosteum  covering  other  bones,  since 
that  membrane  brings  to  the  part  it  covers  a  very 
copious  and  essential  contribution  to  its  blood  supply. 
This  disposition  of  the  pericranium  is  also  well  illus- 
trated by  its  action  in  cases  of  necrosis  of  the  cranial 
bones.  In  necrosis  of  a  long  bone,  the  separation  of 
the  sequestrum  is  attended  with  a  vigorous  periostea! 
growth  of  new  bone,  which  repairs  the  gap  left  after 
the  removal  of  such  sequestra.  In  necrosis  of  the 
vault  of  the  skull,  however,  no  new  bone  is,  as  a 
rule,  formed,  and  the  gap  remains  unrepaired.  The 


6  SuKcrcAL  APPLIED  A  NATO  My.        [Chap,  i 

general  indisposition  of  the  pericranium  to  form  new 
bone  in  other  circumstances  is  frequently  illustrated. 

Abscess  in  the  scalp  region  may  be  situated 
(1)  above  the  aponeurosis,  (2)  between  the  aponeurosis 
and  the  pericranium,  and  (3)  beneath  the  pericranium. 
Abscesses  in  the  first  situation  must  always  be  small 
and  comparatively  insignificant,  since  the  density  of 
the  scalp  tissue  here  is  such  that  suppuration  can 
only  extend  with  the  greatest  difficulty.  Suppuration, 
however,  in  the  second  situation  (in  the  loose  tissue 
beneath  the  aponeurosis)  may  prove  very  sei-ious. 
The  laxity  of  this  tissue  offers  every  inducement  to 
the  abscess  to  extend  when  once  pus  has  found  its 
way  between  the  aponeurosis  and  the  pericranium. 
Suppuration  in  this  area  may  undermine  the  entire 
scalp,  whicli  in  severe  and  unrelieved  cases  nlay  rest 
upon  the  abscess  beneath  as  upon  a  kind  of  water- 
bed.  As  in  scalp  wounds  the  aponeurosis  is  often 
divided,  and  as  suppuration  may  follow  the  injury,  it 
will  be  seen  that  the  chief  danger  of  those  lesions 
depends  upon  the  spreading  of  such  suppuration  to 
the  area  of  lax  connective  tissue  now  under  notice. 
The  significance  of  a  small  amount  of  bare  bone  in  a 
scalp  wound  is  not  so  much  that  evils  will  happen  to 
the  bone,  but  that  the  aponeurosis  has  been  certainly 
divided,  and  the  dangerous  area  of  the  scalp  opened 
up.  Suppuration,  when  it  occurs  in  this  area,  is  only 
limited  by  the  attachments  of  the  occipito-frontalia 
muscle  and  its  aponeurosis,  and  therefore  the  most 
dependent  places  through  which  pus  can  be  evacuated 
are  along  a  line  drawn  round  the  head,  commencing 
in  front,  above  the  eyebrow,  passing  at  the  side  a 
little  above  the  zygoma,  and  ending  behind  at  the 
superior  curved  line  of  the  occipital  bone.  The 
scalp,  even  when  extensively  dissected  up  by  such 
abscesses,  does  not  perish,  since  it  carries,  as  above 
explained,  its  blood  supply  with  it.  The  abscess  is 


chap,  i.)  THE   SCALP,  7 

often  very  slow  to  close,  since  its  walls  are  prevented 
from  obtaining  perfect  rest  by  the  frequent  movement 
of  the  epicranial  muscle.  To  mitigate  this  evil,  and 
to  ensure  closing  of  the  sinuses  in  obstinate  cases, 
Mr.  Hilton  advises  that  the  whole  scalp  be  firmly 
secured  by  strapping,  so  that  the  movement  of  the 
muscle  is  arrested. 

Abscess  beneath  the  pericranitim  must  be  limited 
to  one  bone,  since  the  dipping  in  of  the  membrane  at 
the  sutures  prevents  a  more  extensive  spreading  of 
the  suppuration. 

Haematomata,  or  blood  tumours  of  the 
scalp  region,  occur  in  the  same  localities  as  abscess. 
The  extravasation  of  blood  above  the  aponeurosis 
must  be  of  a  limited  character,  while  that  beneath  it 
may  be  very  extensive.  It  fortunately  happens,  how- 
ever, that  the  cellular  tissue  between  the  aponeurosis 
and  the  pericranium  contains  but  very  few  vessels, 
and  hence  large  extravasations  in  this  tissue  are  un- 
common. 

Extravasations  of  blood  beneath  the  pericranium 
are  generally  termed  cephalhsematomata,  and  are  of 
necessity  limited  to  one  bone.  They  are  usually  con- 
genital, are  due  to  pressure  upon  the  head  at  birth, 
and  are  thus  most  commonly  found  over  one  parietal 
bone,  that  bone  being  probably  the  one  most  exposed 
to  pressure.  Their  greater  frequency  in  male  children 
may  depend  upon  the  larger  size  of  the  head  in  the 
male  foetus.  Such  extravasations  in  early  life  are 
encouraged  by  the  laxity  of  the  pericranium,  and  by 
the  softness  and  vascularity  of  the  subjacent  bone. 

In  the  temporal  region,  or  the  region  corre- 
sponding to  the  temporal  muscle,  the  layers  of  soft 
parts  between  the  skin  and  the  bone  are  somewhat 
different  from  those  that  have  been  already  described 
as  common  to  the  chief  part  of  the  scalp.  There  is  a 
good  deal  of  fat  in  the  temporal  fossa,  and  when  this 


8  SURGICAL  APPLIED  ANATOMY.        |Ch.<»p.  i 

is  absorbed  it  leads  to  more  or  less  prominence  of  the 
zygoma  and  malar  bone,  and  so  produces  the  project- 
ing "  cheek  bones  "  of  the  emaciated.  The  temporal 
muscle  above  the  zygoma  is  covered  in  by  a  very 
dense  fascia,  the  temporal  fascia,  which  is  attached 
above  to  the  tempoi'al  ridge  on  the  frontal  and  pari- 
etal bones,  and  below  to  the  zygomatic  arch.  The 
unyielding  nature  of  this  fascia  is  well  illustrated  by 
a  case  recorded  by  Denonvilliers.  It  concerned  a 
woman  who  had  fallen  in  the  street,  and  who  was 
admitted  into  hospital  with  a  deep  wound  in  the 
temporal  region.  A  piece  of  bone  of  several  lines  in 
length  was  found  loose  at  the  bottom  of  the  wound, 
and  was  removed.  After  its  removal  the  finger  could 
be  passed  through  an  opening  with  an  unyielding 
border,  and  came  in  contact  with  some  soft  substance 
beyond.  The  case  was  considered  to  be  one  of  com- 
pound fracture  of  the  squamous  bone,  with  separation 
of  a  fragment  and  exposure  of  the  brain.  A  by- 
stander, however,  noticed  that  the  bone  removed  was 
dry  and  white,  and  a  more  complete  examination  of 
the  wound  revealed  the  fact  that  the  skull  was  un- 
injured, that  the  supposed  hole  in  the  skull  was 
merely  a  laceration  of  the  temporal  fascia,  that  the 
soft  matter  beyond  was  muscle  and  not  brain,  and  that 
the  fragment  removed  was  simply  a  piece  of  bone 
which,  lying  on  the  ground,  had  been  driven  into  the 
soft  parts  when  the  woman  fell. 

Abscesses  in  the  temporal  fossa  are  prevented 
by  the  fascia  from  opening  anywhere  above  the 
zygoma,  and  are  encouraged  rather  to  spread  into 
the  pterygoid  and  maxillary  regions,  and  into  the  neck. 

The  pericranium  in  the  temporal  region  is  much 
more  adherent  to  the  bone  than  it  is  over  the  rest  of 
the  vault,  and  subpericranial  extravasations  of  blood 
are  therefore  practically  unknown  in  this  part  of  the 
cranial  wall. 


Chap.  I.] 


THE  SCALP. 


Trephining.— This  operation  is  frequently  per- 
formed in  the  temporal  region,  its  object  being  to 
reach  extravasations  of  blood  from  the  middle  menin- 
geal  artery.  This  artery  crosses  the  anterior  inferior 
angle  of  the  parietal  bone  at  a  point  \~  inches  behind 
the  external  angular  process  of  the  frontal  bone,  and 
If  inches  above  the  zygoma. 

In   cutting  down   to   the   bone   m  the  temporal 


D  E 

Fig.  2. — Points  for  Trephining. 

A,  B,  Spots  ftir  trephining  in  middle  Imeningroiil  liivniorrhage ;  c,  ppot  for  tre- 
phining in  abscess  of  the  temporo-sphonoidal  lobe  ;  K,  spot  for  trephining  in 
abscess  of  the  cerebellum ;  u,  mastoid  foramen.  (After  Nancrede.) 

region  the  following  structures  are  met  with  in  order  : 
(1)  The  skin  ;  (2)  branches  of  the  superficial  temporal 
vessels  and  nerves ;  (3)  the  fascia  continued  down 
from  the  epicranial  aponeurosis ;  (4)  the  temporal 
fascia ;  (5)  the  temporal  muscle  ;  (6)  the  deep  temporal 
vessels  ;  and  (7)  the  pericranium. 

Trephining  for  meningcal  hemorrhage. — Unless 
localising  symptoms  give  other  indications,  Kronlein 
advises  that  the  trephine  holes  in  cases  of  meningeal 


io  SURGICAL  APPLIED  ANATOMY.          [Chap. i. 

haemorrhage  be  determined  as  follows  : — A  line  is 
drawn  around  the  skull  at  the  level  of  the  upper  margin 
of  the  orbit,  and  is  throughout  parallel  with  Reid's 
base-line,  Fig.  2.  (See  also  page  35.)  The  trephine 
is  first  placed  at  a  point  on  this  line,  which  is  from  \\ 
to  1^-  inches  (according  to  age  and  size  of  head) 
behind  the  external  angular  process  of  the  frontal 
bone  (A,  Fig.  2).  Should  no  clot  be  revealed,  a  second 
hole  is  made  upon  the  same  line  just  below  the 
parietal  eminence,  and  at  a  point  where  a  vertical  line 
carried  up  from  the  posterior  border  of  the  mastoid 
process  bisects  the  line  already  given  (B,  Fig.  2). 

Trephining  for  intracranial  abscess. — The  abscess 
is  often  due  to  middle-ear  disease,  and  is  then  very 
commonly  found  in  the  temporo-sphenoidal  lobe  or  in 
the  cerebellum.  It  is  estimated  to  be  three  times 
more  common  in  the  cerebrum  than  in  the  cerebellum. 

The  abscess  of  the  temporo-sphenoidal  lobe  is 
usually  found,  according  to  Mr.  Bai'ker,  between  two 
lines  drawn  at  right  angles  to  Reid's  base-line.  These 
lines  are  about  1^  inches  apart ;  one  passes  through 
the  meatus,  the  other  about  1^  inches  behind  that 
opening  (xx,  Fig.  2).  The  trephine  should  be  intro- 
duced in  the  centre  of  the  space  marked  out  by  these 
two  lines,  and  at  a  distance  of  about  li  inches  above 
the  base-line  (c,  Fig.  2). 

In  dealing  with  an  abscess  of  the  cerebellum,  the 
best  spot  to  select  is,  in  the  adult,  1£  inches  behind 
the  centre  of  the  meatus  and  1  inch  below  the  base- 
line (E,  Fig.  2). 

Trephining  for  cerebral  tumour. — The  position 
of  the  opening  in  the  skull  is  obviously  determined 
by  the  localising  symptoms.  It  is  remarkable  that 
little  trouble  from  haemorrhage  has  attended  these 
operations. 

In  any  case,  after  trephining,  the  portion  or 
portions  ot'  bone  removed  may — if  properly  treated— 


chap,  i.i  THE  SCALP.  i  \ 

be  replaced  in  the  opening,  and  will  serve  to  make 
good  the  gap  left  by  the  operation. 

In  trephining  the  skull  generally,  the  comparative 
thickness  of  the  cranial  wall  in  various  parts  should 
be  borne  in  mind  (page  28),  and  the  large  arteries  of 
the  scalp  should  be  avoided  if  possible.  In  order  to 
accommodate  the  instrument  to  the  varying  thickness 
of  the  skull,  the  pin  of  the  trephine  is  not  allowed  to 
protrude  more  than  -^  of  an  inch.  The  trephine 
should  not  be  applied  over  the  frontal  sinuses,  which 
are  often  of  large  size  in  the  aged,  and  should,  when 
possible,  keep  clear  of  the  sutures,  owing  to  the 
frequent  exit  of  emissary  veins  at  or  about  suture 
lines.  The  bone,  moreover,  at  certain  of  these  lines 
is  of  unequal  thickness.  Between  the  bones  forming 
the  sutures  passes  the  sutural  membrane.  This 
structure  blends  with  the  dura  mater,  and  laceration 
of  it  may  conduce  to  meningitis.  Especially  must 
the  superior  longitudinal  sinus  be  avoided,  which 
runs  backwards  in  the  middle  line,  and  the  lateral 
sinus,  whose  course  is  represented  by  a  line  drawn 
horizontally  from  the  occipital  protuberance  to  a  point 
about  one  inch  behind  the  external  meatus  of  the  ear, 
where  it  turns  downwards  to  groove  the  mastoid  process. 

The  zygoma  may  be  broken  by  direct  or  indirect 
violence.  In  the  latter  case  the  violence  is  such  as 
tends  to  thrust  the  upper  jaw  or  malar  bone  back- 
wards. When  due  to  direct  violence,  a  fragment  may 
be  driven  into  the  temporal  muscle,  and  much  pain 
caused  in  moving  the  jaw.  In  ordinary  cases  there  is 
little  or  no  displacement,  since  to  both  fragments  the 
temporal  fascia  is  attached  above  and  the  masseter  below. 

The  vessels  and  nerves  of  the  scalp.— The 
supraorbital  artery  and  nerve  pass  vertically  upwards 
from  the  supraorbital  notch,  which  is  situate  at  the 
junction  of  the  middle  with  the  inner  third  of  the 
upper  orbital  margin.  Nearer  the  middle  line  the 


12  SURGICAL  APPLIED  ANATOMY.        [Chap.  i. 

frontal  artery  and  supratrochlear  nerve  ascend.  This 
artery  gives  life  to  the  flap  that  in  rhinoplasty  is 
taken  from  the  forehead  to  form  a  new  nose.  The  tem- 
poral artery,  with  the  auriculo-temporal  nerve  behind 
it,  crosses  the  base  of  the  zygoma  just  in  front  of 
the  ear.  The  vessel  divides  into  its  two  terminal 
branches  (the  anterior  and  posterior)  two  inches 
above  the  zygoma.  The  branches  of  this  artery, 
especially  the  anterior  branch,  are  often  veiy  tortuous 
in  the  aged,  and  afford  early  evidence  of  arterial 
degeneration.  Arteriotomy  is  sometimes  practised 
on  the  anterior  branch  of  this  vessel.  The  superficial 
temporal  vessels  are  very  liable  to  be  the  seat  of 
cirsoid  aneurism,  as,  to  a  less  extent,  are  the  other 
scalp  arteries.  Cirsoid  aneurism  is  more  often  met 
with  in  the  superficial  temporal  arteries  than  in  any 
other  artery  in  the  body.  The  posterior  auricular 
artery  and  nerve  run  in  the  groove  between  the 
mastoid  process  and  the  ear,  and  the  occipital  artery 
and  great  occipital  nerve  reach  the  scalp  just  internal 
to  a  point  midway  between  the  occipital  protuberance 
and  the  mastoid  process. 

Certain  of  the  emissary  veins  are  of  great 
importance  in  surgery.  These  veins  pass  through 
apertures  in  the  cranial  wall,  and  establish  communi- 
cations between  the  venous  circulation  (the  sinuses) 
within  the  skull  and  the  superficial  veins  external 
to  it.  The  principal  emissary  veins  are  the  following  : 

1.  A  vein  passing  through  the  mastoid  foramen  and 
connecting  the  lateral  sinus  with  the  posterior  auri- 
cular vein  or  with  an  occipital  vein.     This  is  the  largest 
and  most  constant  of  the  series.     The  existence  of 
this    mastoid  vein    serves   to    answer   the    question, 
Why  is  it  a  common  practice  to  apply  leeches  and 
blisters  behind  the  ear  in  certain  cerebral  affections  ? 

2.  A  vein  connecting  the  superior  longitudinal  sinus 
with   the   veins   of    the   scalp    through    the    parietal 


Chap,  i.j  THE  SCALP.  13 

foramen.  3.  A  vein  connecting  the  lateral  sinus  with 
the  deep  veins  at  the  back  of  the  neck  through  the 
posterior  condylar  foramen  (inconstant).  4.  Minute 
veins  following  the  ninth  nerve  through  its  foramen, 
and  connecting  the  occipital  sinus  with  the  deep  veins 
of  the  neck.  5.  Minute  veins  passing  through  the 
foramen  ovale,  foramen  lacerum  and  carotid  canal  to 
connect  the  cavernous  sinus  with  (respectively)  the 
pterygoid  venous  plexus,  the  pharyngeal  plexus,  and 
the  internal  jugular  vein. 

Then,  again,  many  minute  veins  connect  the  veins 
of  the  scalp  with  those  of  the  diploe.  Of  the  four 
diploic  veins,  two  (the  frontal  and  anterior  temporal) 
enter  into  surface  veins  (the  supraorbital  and  deep 
temporal),  and  two  (the  posterior  temporal  and 
occipital)  enter  into  the  lateral  sinus. 

Lastly,  there  is  the  well-known  communication 
between  the  extra-  and  intracranial  venous  circulation 
effected  by  the  commencement  of  the  facial  vein  at 
the  inner  angle  of  the  orbit.  In  this  communication 
the  angular  and  supraorbital  veins  unite  with  the  supe- 
rior ophthalmic  vein,  a  tributary  of  the  cavernous  sinus. 

Through  these  various  channels,  and  through  many 
probably  still  less  conspicuous,  inflammatoiy  processes 
can  spread  from  the  surface  to  the  interior  of  the  skull. 
Thus  we  find  such  affections  as  erysipelas  of  the  scalp, 
diffuse  suppuration  of  the  scalp,  necrosis  of  the 
cranial  bones,  and  the  like,  leading  by  extension  to 
mischief  within  the  diploe,  to  thrombosis  of  the 
sinuses,  and  to  inflammation  of  the  meninges  of  the 
brain.  If  there  were  no  emissary  veins,  injuries  and 
diseases  of  the  scalp  and  skull  would  lose  half  their 
seriousness.  Mischief  may  even  spread  from  within 
outwards  along  an  emissary  vein.  Erichsen  reports  a 
case  where  the  lateral  sinus  was  exposed  in  a  com- 
pound fracture.  The  aperture  was  plugged.  Throm- 
bosis and  suppuration  within  the  sinus  followed,  and 


14  SURGICAL  APPLIED  ANATOMY.      [Chap.  11. 

some  of  the  pus,  escaping  through  the  mastoid  vein, 
led  to  an  abscess  in  the  neck. 

Certain  venous  tumours  are  met  with  on  the  skull. 
They  consist  of  collections  of  venous  blood  under  the 
pericranium  that  communicate,  through  holes  in  the 
skull,  with  the  superior  longitudinal  sinus.  They  are 
median,  are  reducible  on  pressure,  and  receive  a  faint 
pulsation  from  the  brain.  The  holes  are  sometimes  the 
result  of  accident,  others  depend  upon  bone  disease  or 
atrophy  about  a  Pacchionian  body,  and  a  few  are  due 
to  a  varicose  emissary  vein,  or  to  a  congenital  defect 
in  the  cranium. 

The  scalp  nerves,  especially  such  as  are  branches 
of  the  fifth  pair,  are  often  the  seat  of  neuralgia.  To 
relieve  one  form  of  this  affection,  the  supraorbital 
nerve  has  been  divided  (iieurotomy)  at  its  point  of 
exit  from  the  orbit,  and  a  portion  of  the  nerve  has 
been  resected  (neurectomy)  in  the  same  situation. 

Some  forms  of  frontal  headache  depend  upon  neu- 
ralgia of  this  nerve.  The  inner  branch  of  the  nerve 
reaches  the  middle  of  the  parietal  bone ;  the  outer 
branch,  the  lambdoid  suture. 

The  lymphatics  from  the  occipital  and  posterior 
parietal  regions  of  the  scalp  enter  the  suboccipital  and 
mastoid  glands ;  those  from  the  frontal  and  anterior 
parietal  regions  go  to  the  parotid  glands,  while  some  of 
the  vessels  from  the  frontal  region  join  the  lymphatics 
of  the  face,  and  end  in  the  submaxillary  glands. 


CHAPTER  II. 

THE  BONY  VAULT  OF  THE  CRANIUM. 

Position  of  the  sutures.— The  bregma,  or 
point  of  junction  of  the  coronal  and  sagittal  sutures, 
is  in  a  line  drawn  vertically  upwards  from  a  point  just 
in  front  of  the  external  auditory  meatus,  the  head 


Chap,  ii.]      BONY  VAULT  OF  THE  CRANIUM.  15 

being  in  normal  position  (Fig.  2).  The  lambda,  oi 
point  of  junction  of  the  lambdoid  and  sagittal  sutures, 
lies  in  the  middle  line,  about  2f-  inches  above  the 
occipital  protuberance.  The  lambdoid  suture  is  fairly 
represented  by  the  upper  two-thirds  of  a  line  drawn 
from  the  lambda  to  the  apex  of  the  mastoid  process 
on  either  side.  The  coronal  suture  lies  along  a  line 
drawn  from  the  bregma  to  the  middle  of  the  zygo- 
matic  arch.  On  this  line,  at  a  spot  about  on  a 
level  with  the  external  angular  process  of  the  frontal 
bone,  and  about  \\  inches  behind  that  process,  is 
the  pterion,  the  region  where  four  bones  meet,  viz.  the 
squamous  bone,  the  great  wing  of  the  sphenoid,  the 
frontal  and  parietal  bones.  The  summit  of  the  squa- 
mous suture  is  1|  inches  above  the  zygoma. 

In  the  normal  subject  all  traces  of  the  ibntanelles 
and  other  unossitied  parts  of  the  skull  disappear 
before  the  age  of  four  years.  The  anterior  fontanelle 
is  the  last  to  close,  while  the  posterior  is  already  filled 
at  the  time  of  birth.  It  is  .through  or  about  the 
anterior  fontanelle  that  the  ventricles  are  usually 
tapped  in  paracentesis  in  cases  of  hydrocephalus.  In 
this  operation  the  trochar  is  either  entered  at  the  sides 
of  the  fontanelle  at  a  sufficient  distance  from  the 
middle  line  to  avoid  the  sinus,  or  is  introduced 
through  the  coronal  suture  at  some  spot  other  than  its 
middle  point.  It  may  be  noted  that  in  severe  hydro- 
cephalus the  coronal  and  other  sutures  of  the  vault 
are  widely  opened. 

The  condition  known  as  cranio-tafoes,  a  con- 
dition assigned  by  some  to  rickets  and  by  others  to 
inherited  syphilis,  is  usually  met  with  in  the  vertical 
part  of  the  occipital  bone,  and  in  the  adjacent  parts  of 
the  parietal  bones,  but  especially  in  the  posterior 
inferior  angles  of  these  bones.  In  this  condition  the 
bone  is  greatly  thinned  in  spots,  and  its  tissue  so 
reduced  that  the  affected  district  feels  to  the  finger  as 


1 6  SURGICAL  APPLIED  ANATOMY.       [Chap.n 

if  occupied  by  parchment,  or,  as  some  suggest,  by 
cartridge  p-vper.  The  thinning  is  mainly  at  the 
expense  of  the  inner  table  and  diploe.  The  pits  are 
situated  in  early  formed  convolution  impressions.  It 
is,  on  the  other  hand,  about  the  site  of  the  anterior 
fontanelle  that  certain  osseous  deposits  are  met  with 
on  the  surface  of  the  skull  in  some  cases  of  hereditary 
syphilis  (Parrot).  These  deposits  appear  as  rounded 
elevations  of  porous  bone  situated  upon  the  frontal 
and  parietal  bones,  where  they  meet  in  the  middle 
line.  These  bosses  are  separated  by  a  crucial  depres- 
sion represented  by  the  frontal  and  sagittal  sutures  on 
the  one  hand,  and  the  coronal  suture  on  the  other. 
They  have  been  termed  "  natiform  "  elevations  by  M. 
Parrot,  from  their  supposed  resemblance,  when  viewed 
collectively,  to  the  nates.  To  the  English  mind  they 
would  rather  suggest  the  outlines  of  a  "  hot-cross 
bun." 

It  is  necessary  to  refer  to  the  development  ol 
the  skull  in  order  to  render  intelligible  certain  con- 
ditions (for  the  most  part  those  of  congenital  mal- 
formation) that  are  not  unfrequently  met  with. 
Speaking  generally,  it  may  be  said  that  the  base  of 
the  skull  is  developed  in  cartilage,  and  the  vault  in 
membrane.  The  parts  actually  formed  in  membrane 
are  represented  in  the  completed  skull  by  the  frontal 
and  parietal  bones,  the  squamo-zygomatic  part  of  the 
temporal  bone,  and  the  greater  part  of  the  expanded 
portion  of  the  occipital  bone.  The  distinction  between 
these  two  parts  of  the  skull  is  often  rendered  very 
marked  by  disease.  Thus  there  are,  in  the  museum 
of  the  Royal  College  of  Surgeons,  the  skulls  of  some 
young  lions  that  were  born  in  a  menagerie,  and  that, 
in  consequence  of  mal-nutrition,  developed  certain 
changes  in  their  bones.  A  great  part  of  each  of 
these  skulls  shows  considerable  thickening,  the  bone 
being  converted  into  a  porous  structure ;  and  it  is 


Chap,  ii.]     BONY  VAULT  OF  THE  CRANIUM. 


remarkable  to  note  that  these  changes  are  limited  to 
such  parts  of  the  skull  as  are  formed  in  membrane, 
the  base  remaining  free. 

Among  the  more  common  of  the  gross  mal- 
formations of  the  skull  also,  is  one  that  shows 
entire  absence  of  all  that  part  of  the  cranium  that  is 
formed  in  membrane,  while  the  base,  or  cartilaginous 
part,  is  more  or  less  perfectly  developed. 

Mciiingoccle  is  the  name  given  to  a  congenital 
tumour  that  consists  of  a  protrusion  of  a  part  of  the 
cerebral  membranes  through  a  gap  in  an  imperfectly 
developed  skull.  When  the  protrusion  contains  brain, 
it  is  called  an  encephalocele,  and  when  that  pro- 
truded brain  is  distended  by  an  accumulation  of  fluid 
within  the  ventricles,  it  is  called  hydrencephalocele. 
These  protrusions  are  most  often  met  with  in  the 
occipital  bone,  and  next  in  frequency  in  the  fronto- 
nasal  suture,  while  in  rarer  cases  they  have  been  met 
with  in  the  lambdoid,  sagittal,  and 
other  sutures,  and  have  projected 
through  normal  and  abnormal  fis- 
sures at  the  base  of  the  skull 
into  the  orbit,  nose,  and  mouth. 
Their  frequency  in  the  occipital 
bone  may  be  in  some  way  ex- 
plained by  a  reference  to  the 
development  of  that  part.  This 
bone  at  birth  consists  of  four 
separate  parts  (see  Fig.  3),  a  basi- 
lar,  two  condylar,  and  a  tabular 
or  expanded  part.  In  the  tabular 
part,  about  the  seventh  week  of 
foetal  life  four  nuclei  appear,  an 
upper  and  a  lower  pair.  These  nuclei  are  to  some 
extent  separated  by  fissures  running  inwards  from 
the  four  angles  of  the  bone  to  meet  at  the  occi- 
pital protuberance.  The  gap  running  up  in  the 
C— 4 


Fig.  3.— The  Occipital 
Bone  at  Birth. 


i8 


SURGICAL  APPLIED  ANATOMY.      [Chap.  n. 


median  line  from  the  inferior  angle  at  the  fora 
men  magnum  to  the  occipital  protuberaiice  is  es- 
pecially distinct  (the  temporary  occipital  fontanelle 
of  Button).  It  exists  from  the  beginning  of  the  third 
to  the  end  of  the  fourth  month  of  intrauterine  life. 
Meningoceles  of  the  occiput  are  always  in  the  middle 
line,  and  the  pi-otrusion  probably  occurs  through  this 


Fig.  4.— Back  View  of  Abnormal  Skulls,  showing  Occipital  and 

Parietal  Bones. 
A,  The  "  os  epactal  "  ;  B,  parietal  fissures ;  c,  the  sagittal  fontanelle. 

gap.  The  gap  associated  with  meningocele  may  ex- 
tend through  the  whole  vertical  length  of  the  occipital 
bone,  and  very  commonly  opens  up  the  foramen 
magnum.  The  lateral  or  transverse  fissures  divide 
the  bone  into  two  parts.  The  upper  part  is  developed 
from  membrane,  the  lower  part  from  cartilage.  The 
lateral  fissures  may  persist,  and  may  simulate  fractures, 
for  which  they  have,  indeed,  been  mistaken;  or  they  may 
be  so  complete  as  to  entirely  separate  the  highest  part  of 
the  occipital  bone  from  the  remainder.  The  bone  so 


chap,  ii.)     BONY  VAULT  OF  THE  CRANIUM.  19 

separated  is  the  os  epuctal  of  the  French  (Fig.  4  A), 
the  interparietal  bone  of  some  animals. 

Parietal  fissures. — In  the  developing  parietal 
bone,  fibres  concerned  in  ossification  radiate  towards  the 
periphery  from  t\vo  nuclei  about  the  centre  of  the  bone. 
An  interfibrillar  space,  larger  than  the  rest,  is  seen  about 
the  fifth  month  to  separate  the  loose  osseous  fibres  which 
abut  on  the  posterior  part  of  the  sagittal  border  from  the 
stronger  fibres  which  form  the  rest  of  this  border  (Pozzi). 
This  is  the  parietal  fissure.  It  usually  closes  and  leaves 
no  trace,  but  it  may  persist  in  part  as  a  suture-like 
fissure,  and  be  mistaken  for  a  fracture  (Fig.  4  B).  If 
the  fissure  persists  equally  on  the  two  sides  an  elong- 
ated lozenge-shaped  gap  is  left,  the  sagittal  fontanelle. 
It  is  situate  about  an  inch  in  front  of  the  lambda  (Fig. 
4  c).  The  parietal  foramina  are  remains  of  this  interval. 

Wormian  bones. — These  irregular  bones  may 
be  mistaken  for  fragments  produced  by  fracture. 
They  are  most  usually  met  with  in  the  lambdoid 
suture.  One  Wormian  bone  deserves  especial  notice, 
as  it  may  be  met  with  in  trephining  over  the  middle 
meningeal  artery.  It  exists  between  the  anterior 
inferior  angle  of  the  parietal  bone  and  the  great  wing 
of  the  sphenoid.  It  is  scale-like,  and  gives  the  im- 
pression that  the  tip  of  the  great  wing  had  been 
separated.  It  is  known  as  the  epipteric  bone. 

Necrosis  is  fairly  common  on  the  vault  of  the 
skull,  and  most  often  attacks  the  frontal  and  parietal 
bones,  while,  for  reasons  that  are  not  very  obvious,  it 
is  rare  in  the  occipital  bone.  The  external  table  is 
frequently  necrosed  alone,  it  being  more  exposed  to 
injury  and  less  amply  supplied  with  blood  than  is  the 
internal  table.  From  the  converse  of  these  reasons 
it  happens  that  necrosis  of  the  internal  table  alone  is 
but  rarely  met  with.  Necrosis  involving  the  entire 
thickness  of  the  bone  may  prove  very  extensive,  and 
in  a  case  reported  by  Saviard,  practically  the  whole  of 


so  SURGICAL  APPLIED  ANATOMY.      ichap.  H. 

the  cranial  vault  necrosed  and  carne  away.  The  patient 
was  a  woman,  and  the  primary  cause  of  the  mischief 
was  a  fall  upon  the  head  when  drunk.  (See  page  5.) 

Necrosis  of  the  skull,  as  well  as  caries  of  the  part, 
is  attended  by  certain  special  dangers  that  depend 
upon  the  anatomical  relations  of  the  cranial  bones. 

Thus,  when  the  whole  thickness  of  the  skull  is 
involved  by  disease,  or  when  the  inner  table  is 
especially  attacked,  a  collection  of  pus  may  form 
between  the  dura  mater  and  the  affected  bone,  and 
may  produce  compression  of  the  brain.  When  the 
diploic  tissue  is  implicated,  the  veins  of  that  part  may 
become  thrombosed,  or  may  be  the  seat  of  a  suppurative 
phlebitis.  The  mischief  thus  commenced  may  spread, 
the  great  intracranial  sinuses  may  be  closed  by  throm- 
bus, or  septic  matter  may  be  conveyed  into  the  general 
circulation  and  lead  to  the  development  of  pyjemia. 

Mere  local  extension  may  also  cause  meningitis. 

In  cases  of  necrosis  of  the  external  table  the 
growth  of  granulation  tissue  from  the  exposed  and 
vascular  diploe  plays  a  very  important  part  in  aiding 
the  exfoliation  of  the  lamella  of  dead  bone. 

When  bone  disease  leads  to  perforation  of  the  skull, 
the  pulsations  of  the  brain  may  be  visible  through  the 
abnormal  opening. 

Fractures  of  the  skull. — It  is  not  easy  to 
actually  fracture  the  skull  of  a  young  infant.  The  skull 
as  a  whole  at  this  age  is  imperfectly  ossified,  the  sutures 
are  wide,  and  between  the  bones  there  is  much 
cartilage  and  membrane.  Moreover,  the  bones  them- 
selves in  early  life  are  elastic,  and  comparatively  soft 
and  yielding.  If  a  blow  be  inflicted  upon  the  vault 
in  a  young  child  the  most  probable  effect,  so  far  as 
the  bone  itself  is  concerned,  is  an  indenting  or 
bulging  in  of  that  bone  unassociated  with  a  fracture 
in  the  ordinary  sense.  In  this  particular  relation,  the 
skull  of  an  infant  is  to  that  of  an  old  man  as  a 


chap,  i i.i    BONY  VAULI  OF  THE  CRANIUM.  21 

cranium  of  thin  tin  would  be  to  a  cranium  of  strong 
earthenware.  The  yielding  character  of  the  young 
child's  skull  is  well  illustrated  by  the  gross  deformity 
of  the  head  that  certain  Indian  tribes  produce  in  their 
offspring  by  applying  tight  bandages  to  the  part  in 
infancy.  In  the  Royal  College  of  Surgeons'  museum 
are  many  skulls  of  "  flat-headed  "  Indians,  that  show 
to  what  an  extreme  this  artificial  deformity  may  be 
carried.  Gueniot  also  asserts  that  much  deformity  of 
the  head  may  be  produced  in  infants  by  the  practice 
of  allowing  them  to  always  lie  upon  one  side  of  the 
body.  Here  the  deforming  agent  is  simply  the  weight 
of  the  brain. 

Even  in  adults  the  skull  is  much  less  brittle  than 
is  commonly  supposed,  and  notions  as  to  the  break- 
ability  of  the  cranial  bones  derived  from  the  study 
of  the  dried  specimen  are  apt  to  be  erroneous.  During 
life,  a  sharp  knife  properly  directed  may  be  driven 
through  the  cranial  vault  so  as  to  cause  only  a  simple 
perforating  wound  without  splintering,  and  without 
fracture  of  the  bone  beyond  the  puncture.  Such  a 
wound  may  be  as  cleanly  cut  as  a  wound  through 
thick  leather,  and  a  specimen  in  the  London  Hospital 
museum  serves  well  to  illustrate  this.  A  case  reported 
in  the  Lancet  for  1881  affords  a  strange  instance 
of  a  knife  penetrating  the  skull  without  apparently 
splintering  the  bone.  A  man  wishing  to  commit 
suicide  placed  the  point  of  a  dagger  against  the  skull 
in  the  upper  frontal  region,  and  then  drove  it  well 
into  the  brain  by  a  blow  from  a  mallet.  He  expected 
to  fall  dead,  and  was  disappointed  to  find  that  no 
phenomena  of  interest  developed.  He  then  drove  the 
dagger  farther  in  by  some  dozen  blows  with  the 
mallet,  until  the  blade,  which  was  four  inches  long, 
was  brought  to  a  standstill.  The  dagger  was  removed 
with  great  difficulty,  the  patient  never  lost  conscioxis- 
ness,  and  recovered  without  a  symptom. 


22  SURGICAL  APPLIED  ANATOMY.      [Chap.  n. 

The  following  anatomical  conditions  tend  to 
minimise  the  effects  of  violence  as  applied  to  the  skull : 
The  density  of  the  scalp  and  its  great  mobility ;  the 
dome-like  arrangement  of  the  vault ;  the  number  of 
the  bones  that  compose  the  head,  and  the  tendency  of 
the  violence  to  be  broken  up  amongst  the  many  seg- 
ments ;  the  sutures  which  interrupt  the  continuity  of 
any  given  force,  and  the  sutural  membrane,  which  acts 
as  a  kind  of  linear  buffer ;  the  mobility  of  the  head 
upon  the  spine  ;  and  the  elasticity  of  the  cranial  bones 
themselves. 

In  children  the  membranous  layer  between  the 
sutui'es  is  of  considerable  thickness,  but,  as  age 
advances,  this  membrane  disappears,  and  the  bones 
tend  to  fuse  together  (synostosis).  The  sutures  begin 
to  be  obliterated  about  the  age  of  forty,  the  change 
commencing  on  the  inner  aspect  of  the  suture,  and 
appearing  first  in  the  sagittal  suture,  then  in  the 
coronal  and  lambdoid,  and  last  in  the  squamous.  The 
synostosis  may  be  complete  by  the  age  of  eighty 
(Tillaux),  and  its  onset  is  said  to  be  coincident  with 
the  cessation  of  increase  in  the  weight  of  the  brain. 
This  latter  assertion  is  supported  by  the  fact  that  it 
appears  earlier  in  the  lower  races  of  mankind.  As 
age  advances,  moreover,  the  skull  bones  become  less 
porous,  and  lose  much  of  their  elasticity.  They  are, 
therefore,  more  readily  fractured  in  the  aged  than  in 
the  young. 

As  a  rule,  in  fracture  the  entire  thickness  of  the 
bone  is  involved  ;  but  the  external  table  alone  may  be 
broken,  and  may  even  be  alone  depressed,  being 
driven  into  the  diploe,  or,  in  the  case  of  the  lower 
frontal  region,  into  the  frontal  sinus.  The  internal 
table  may  be  broken  without  a  corresponding  fracture 
in  the  outer  plate  ;  and  in  nearly  all  cases  of  complete 
fracture,  especially  in  such  as  are  attended  with 
depression,  the  internal  table  shows  more  extensive 


Chap,  ii.]     BONY  VAULT  OF  THE  CRANIUM, 


splintering  than  does  the  external.  There  are  many 
reasons  for  this.  The  internal  plate  is  not  only 
thinner  than  the  external,  but  is  so  much  more 
brittle  as  to  receive  the  name  of  the  "  vitreous  table." 
A  force  applied  to  the  external  table  may  be  extremely 
limited,  and  produce,  as  in  a  sabre  cut,  but  a 
limited  lesion.  As  the  force,  however,  travels 
through  the  diploe  it  becomes  broken  up,  and 
reaches  the  inner  plate  as  a  much  more  diffused 

form  of  violence.  This 
is  especially  the  case 
when  parts  of  the 
outer  table  are  driven 
in.  Then,  again,  the 
\.  internal  plate  is  a 
part  of  a  smaller 
curve  than  is  the  ex- 
ternal plate ;  and, 
lastly,  Agnew  assigns 
a  reason  for  the 
greater  vulnerability  of  the  inner  plate  that  has 
reference  to  the  general  yielding  of  the  bone.  In 
Fig.  5,  A  B  represents  a  section  of  a  part  of  the 
vault  through  both  c  U 

tables,  and  c  D  and  / 

E  F  two  vertical  and  / 

parallel  lines.  Now, 
if  force  be  applied 
to  the  vault  between 
these  parallel  lines, 

the  ends  of  the  arch,    ^  D  I 

A  B,  will  tend  to  be-  Fig.  6. 

come  separated,  and 

the  whole  arch,  yielding,  will  tend  to  assume  the  curve 
shown  in  Fig.  6.  In  such  case,  the  lines  c  D  and  E  F 
will  converge  above  and  diverge  below  (Fig.  6),  so 
that  the  violence  would  tend  to  force  the  bone 


24  SURGICAL  APPLIED  ANATOMY.      [Chap,  n 

particles  together  at  the  outer  table  and  asunder  at 
the  inner  table. 

Fractures  of  the  vault  are  due  to  direct 
violence.  The  construction  of  the  skull  is  such  that 
the  fracturing  force  is  resisted  in  many  ways.  (1)  When 
a  blow  is  received  on  the  vertex  in  the  parietal  region, 
the  force  tends  to  drive  the  upper  borders  of  the 
two  parietal  bones  inwards.  Such  driving  in  of  these 
borders  must  be  associated  with  a  corresponding 
outward  movement  of  the  inferior  borders.  This 
latter  movement  is  forcibly  resisted  by  the  squamous 
bone  and  the  great  wing  of  the  sphenoid,  which  over- 
lap the  lower  edge  of  the  parietal  bone.  Moreover, 
the  force  transmitted  to  the  squamous  bone  is  passed 
on  to  the  zygomatic  arch,  which  takes  its  support 
from  the  superior  maxillary  and  frontal  bones.  This 
arch  then  acts  as  a  second  resisting  buttress,  and  this 
transmission  of  force  from  the  vertex  to  the  facial 
bones  is  said  to  be  illustrated  by  the  pain  often 
felt  in  the  face  after  blows  upon  the  top  of  the 
head.  (2)  If  the  upper  part  of  the  frontal  bone  be 
struck,  the  force  is  at  once  transmitted  to  the  parietal 
bones,  because  the  upper  paz*t  of  the  frontal  bone 
(owing  to  the  manner  in  which  its  border  is  bevelled) 
actually  rests  upon  the  two  parietal  bones,  so  the 
same  resistance  is  again  called  into  action.  If  there  be 
any  tendency  for  the  inferior  parts  of  the  bone  to  move 
outwards,  as  would  certainly  be  the  case  while  the  mid- 
frontal  suture  existed,  such  movement  would  be  resisted 
by  the  great  wings  of  the  sphenoid,  and  by  the  anterior 
inferior  angles  of  the  parietal  bones  which  embrace 
or  overlap  these  parts  of  the  frontal.  Thus  it  will  be 
seen  that  much  depends  upon  the  manner  in  which 
the  corresponding  edges  of  the  frontal  and  parietal 
bones  are  bevelled.  (3)  Blows  upon  the  occiput  are 
less  distinctly  provided  for,  and  it  must  be  owned 
that  a  by  no  means  heavy  fall  is  suflicient  to  break 


chap,  ii.]     BONY  VAULT  OF  THE  CRANIUM.  25 

this  bone.  It  must  receive,  however,  much  protection 
from  its  connections  with  the  two  parietal  and  tem- 
poral bones,  and  from  its  articulation  with  the  elastic 
vertebral  column. 

Fractures  of  the  base  of  the  skull  may  be 
due  to  (1)  direct  or  to  (2)  indirect  violence,  and,  most 
commonly  of  all,  to  (3)  extension  of  a  fracture  from 
the  vault.  (1)  The  base  has  been  fractured  by  direct 
violence  by  foreign  bodies  thrust  through  the  nasal 
roof,  through  the  orbital  roof,  and  through  the  base  as 
it  presents  in  the  pharynx.  The  posterior  fossa  can 
also  be  fractured  by  violence  applied  to  the  nape  of  the 
neck.  (2)  Of  fractures  by  indirect  violence  the  following 
examples  may  be  given  :  Blows  applied  to  the  lower 
part  of  the  frontal  bone  have  been  associated  with  no 
lesion  other  than  a  fracture  of  the  cribriform  plate  or 
of  the  orbital  part  of  the  frontal,  these  parts  being 
much  disposed  to  fracture  on  account  of  their  extreme 
tenuity.  In  falls  upon  the  chin,  the  condyle  of  the 
lower  jaw  has  been  so  violently  driven  against  the 
glenoid  cavity  as  to  fracture  the  middle  fossa  of  the 
skull.  Chassaignac  gives  a  case  where  the  condyle 
was  actually  thrust  into  the  cranial  cavity,  and 
produced  an  abscess  in  the  superimposed  part  of  the 
brain.  When  the  body  in  falling  has  alighted  upon 
the  feet,  knees,  or  buttocks,  the  force  has  been  trans- 
mitted along  the  vertebral  column,  and  has  led  to 
fracture  of  the  base  in  the  occipital  region.  Such 
accidents  are  most  apt  to  occur  when  the  spine  is  kept 
rigid  by  muscular  action,  and  the  mechanism  involved 
is  precisely  similar  to  that  whereby  the  head  of  a 
broom  is  driven  more  firmly  on  to  the  broom-handle 
by  striking  the  extreme  end  of  the  stick  against  the 
ground.  The  theory  that  the  base  is  often  broken  by 
contre-coup  is  pretty  generally  abandoned,  although 
there  are  a  few  cases  that  appear  to  support  the 
suggestion.  Such  a  case  was  recorded  by  Mr. 


26  SURGICAL  APPLIED  ANATOMY.      [Chap.  n. 

Hutchinson,  and  in  it  a  fractm-e  of  the  occipital  bone 
was  associated  with  a  like  lesion  in  the  cribriform 
plate,  the  intervening  part  of  the  skull  being  un- 
injured. (3)  Fractures  of  the  vault,  and  especially 
linear  fractures  due  to  such  diffused  violence  as 
obtains  in  a  fall  upon  the  head,  are  very  apt  to  spread 
to  the  base.  In  so  spreading  they  reach  the  base  by 
the  shortest  possible  route,  and  without  any  regard  to 
the  sutures  encountered  or  to  the  density  of  the  bones 
involved.  Thus,  fractures  of  the  frontal  region  of  the 
vaiilt  spread  to  the  anterior  fossa  of  the  base,  those  of 
the  parietal  region  to  the  middle  fossa,  and  those  of 
the  occipital  region  to  the  posterior  fossa.  To  this 
rule  there  are  but  few  exceptions.  To  indicate  more 
precisely  the  exact  bones  involved  in  these  three 
districts,  P.  Hewett  has  divided  the  skull  into  three 
zones.  The  anterior  zone  includes  the  frontal,  the 
upper  part  of  the  ethmoid,  and  the  fronto-sphenoid ; 
the  middle,  the  parietals,  the  squamous,  the  anterior 
pai't  of  the  petrous  portion,  and  the  greater  part  of 
the  basi-sphenoid ;  and  the  posterior,  the  occipital, 
the  mastoid,  the  posterior  part  of  the  petrous  bone, 
with  a  small  part  of  the  body  of  the  sphenoid. 

In  all  fractures  of  the  base  there  is  usually  a  dis- 
charge of  blood  and  of  cerebro-spinal  fluid  externally. 
(1)  In  fractures  of  the  anterior  fossa  the  blood  usually 
escapes  from  the  nose,  and  is  derived  from  the  menin- 
geal  vessels,  or  in  greater  degree  probably  from  the 
torn  mucous  lining  of  the  nasal  roof.  To  allow  of  the 
escape  of  cerebro-spinal  fluid  from  the  nose,  there 
must  be,  in  addition  to  the  fracture  in  the  nasal  roof, 
a  laceration  of  the  mucous  membrane  below  that 
fracture,  and  of  the  dura  mater  and  arachnoid  above 
it.  In  many  cases  of  fracture  in  this  part  the  blood 
finds  its  way  into  the  orbit,  and  appears  beneath  the 
conjunctiva.  (2)  When  the  middle  fossa  is  involved, 
the  blood  escapes  from  the  external  auditory  rneatus, 


chap,  ii.j     BONY  VAULT  OF  THE  CRANIUM.  27 

through  a  rupture  in  the  tympanic  membrane,  and  ia 
derived  from  the  vessels  of  the  tympanum  and  its 
membrane,  or  from  an  intracranial  extravasation,  and 
in  some  cases  from  a  rupture  of  one  of  the  sinuses 
about  the  petrous  bone.  The  blood  may  follow  the 
Eustachian  tube,  and  may  escape  from  the  nose  or 
mouth,  or  be  swallowed  and  subsequently  vomited. 
To  allow  of  the  escape  of  cerebro-spinal  fluid  by  the 
ear  ("  the  serous  discharge "),  (A)  the  fracture  must 
have  passed  across  the  internal  auditory  meatus ;  (B) 
the  tubular  prolongation  of  the  membranes  in  that 
meatus  must  have  been  torn;  (c)  there  must  be  a  com- 
munication between  the  internal  ear  and  the  tympa- 
num ;  and  (D)  the  membrana  tympana  must  have  been 
lacerated.  (3)  In  fractures  of  the  posterior  fossa  an 
extravasation  of  blood  may  appear  about  the  mastoid 
process  or  at  the  nape  of  the  neck,  or  may  even 
extend  into  the  cervical  region. 

It  may  be  added  that  in  compound  fractures  of  the 
vault  associated  with  tearing  of  the  dura  mater  and 
arachnoid,  an  escape  of  cerebro-spinal  fluid  has  in  a 
few  rare  instances  been  noted.  After  simple  fracture 
of  the  vault  in  children  a  swelling  may  form  at  the 
injured  part,  which  fluctuates,  becomes  tenser  when 
the  patient  cries,  and  may  possibly  pulsate  synchro- 
nously with  the  brain.  Such  swellings  are  due  to  a 
collection  of  cerebro-spinal  fluid  beneath  the  scalp,  and 
indicate  a  coincident  rupture  of  the  brain  membranes. 
In  cases  of  free  serous  discharge  from  the  ear  after 
injury  to  the  head,  but  without  fracture,  the  fluid  is 
derived  from  the  mastoid  cells,  and  escapes  through  a 
rupture  in  the  tympanic  membrane.  In  a  few  instances 
it  may  possibly  be  blood  serum,  or  depend  upon  mild 
catarrh  of  the  meatus.  Some  authors  assert  that  it 
may  be  due  to  the  escape  of  the  liquor  Ootunnii,  but 
the  very  minute  quantity  of  that  fluid  in  the  ear 
renders  the  suggestion  improbable. 


28  SURGICAL  APPLIED  ANATOMY.      [Chap.  IL 

Separation  of  sutures. — This  condition,  as  the 
result  of  injury,  is  practically  restricted  to  the  young 
skull.  In  later  life,  force  applied  at  the  site  of  an 
obliterated  suture  may  cause  a  fracture,  which  accu 
rately  follows  the  old  suture  line.  Separation  of  the 
sutures,  independent  of  fracture,  is  very  rare  in  the 
adult  skull.  In  the  few  instances  of  such  a  condition 
the  temporal  bone  has  usually  been  the  one  displaced, 
and  the  separation  noted  at  the  squamous  suture. 
When  associated  with  fracture,  the  coronal  and 
sagittal  sutures  are  those  most  frequently  separated, 
and  next  in  frequency  the  lambdoid. 

The  thickness  of  the  skull  cap  varies  greatly, 
not  only  in  different  parts  of  the  same  skull,  but  also 
in  corresponding  parts  in  different  individuals.  The 
average  thickness  is  one-fifth  of  an  inch.  The  thickest 
parts  are  at  the  occipital  protuberance  (where  the 
section  may  measure  half  an  inch),  the  mastoid  pro- 
cess, and  the  lower  part  of  the  frontal  bone.  The 
bone  over  the  inferior  occipital  fossae  is  very  thin, 
while  it  is  thinnest  over  the  squamous  bone.  Here 
the  bone  may  be  no  thicker  in  parts  than  a  visiting 
card.  The  skull  is  also  thinned  over  the  sinuses  and 
grooves  for  the  meningeal  vessels.  It  is  especially 
thin  over  the  anterior  inferior  angle  of  the  parietal 
bone.  It  is  important  to  remember  in  trephining  that 
the  inner  table  is  not  always  parallel  with  the  outer. 

Craniectomy. — This  operation  is  carried  out  in 
cases  of  microcephaly  in  infants  and  children.  It 
consists  in  the  removal  of  a  strip  of  bone  from  the 
vertex  of  the  skull  so  as  to  give  to  the  brain,  as  an 
American  author  expresses  it,  "more  elbow  room." 


CHAPTER  IIL 

THE    CRANIAL    CONTENTS. 

THE   membrunes  of  the  brain. — The  dura 

mater,  from  its  toughness,  forms  an  excellent  protec- 
tion to  the  brain.  It  is  very  intimately  adherent  to 
the  bone  over  the  whole  of  the  base  of  the  skull,  and 
consequently  in  this  situation  extravasations  between 
the  membrane  and  the  bone  are  scarcely  possible. 
Over  the  vault  its  attachments  are  comparatively  loose, 
although  it  is  more  closely  adherent  along  the  lines  of 
the  sutures.  This  lax  attachment  allows  large  hsemorr- 
hagic  and  purulent  extravasations  to  collect  between 
the  dura  mater  and  the  bone.  Such  extravasations 
usually  lead  to  compression  of  the  brain,  and  it  may  be 
noted  that  in  the  great  majority  of  all  cases  of  com- 
pression the  compressing  force  is  outside  the  dura 
mater.  Thus,  in  uncomplicated  cases,  when  symptoms 
of  compression  come  on  at  the  time  of  an  accident,  the 
cause  is  probably  depressed  bone ;  when  they  appear 
after  a  short  interval,  the  cause  is  probably  extrava- 
sated  blood  between  the  membrane  and  the  bone ;  and 
when  a  long  interval  (days  or  weeks)  has  elapsed  after 
the  accident,  the  cause  is  probably  a  collection  of  pus 
in  the  same  situation. 

Sir  C.  Bell  pointed  out  that  the  dura  mater  of 
the  vault  may  be  separated  from  the  bone  by  the 
vibration  produced  by  a  blow.  "  Strike  the  skull  of 
a  subject  with  a  heavy  mallet ;  on  dissecting  you  find 
the  dura  mater  to  be  shaken  from  the  skull  at  the 
point  struck.  Repeat  the  experiment  on  another  sub- 
ject, and  inject  the  head  minutely  with  size  injection, 
and  you  will  find  a  clot  of  injection  lying  betwixt  the 


jo  SURGICAL  APPLIED  ANATOMY.     [Chap,  in 

skull  and  dura  mater  at  the  part  struck,  and  having 
an  exact  resemblance  to  the  coagulum  found  after 
violent  blows  on  the  head."  Tillaux  has  demonstrated 
that  the  adhesions  between  the  dura  mater  and  the 
bone  are  particularly  weak  in  the  temporal  fossae, 
the  most  usual  site  of  meningeal  haemorrhage. 

When  blood  is  poured  out  between  the  dura  mater 
and  the  bone  in  cases  of  fracture,  the  vessel  that,  as  a 
rule,  gives  way,  is  the  middle  meningeal  artery 
In  thirty-one  cases  of  such  haemorrhage,  this  vessel  was 
the  source  of  the  bleeding  in  twenty-seven  instances 
(P.  Hewett).  The  vessel  having  passed  through  the 
foramen  spinosum,  divides  into  two  branches ;  the 
anterior,  the  larger,  runs  upwards  across  the  anterior 
inferior  angle  of  the  parietal  bone ;  the  posterior  runs 
backwards,  with  a  horizontal  sweep  across  the  squa- 
rnous  bone. 

Mr.  Jacobson  has  shown  that  the  branches  of  the 
artery  are  more  frequently  ruptured  than  the  trunk. 
The  vessel  is  very  frequently  torn  as  it  crosses  the 
anterior  angle  of  the  parietal  bone.  There  are  many 
reasons  for  this :  the  bone  where  grooved  by  the 
artery  is  very  thin  ;  the  artery  is  often  so  embedded 
in  the  bone  that  fracture  without  laceration  of  the 
vessel  would  hardly  be  possible ;  and  lastly,  the  par- 
ticular region  of  the  artery  is  a  part  of  the  skull 
peculiarly  liable  to  be  fractured.  Mr.  Jacobson  shows 
that  the  artery  may  be  ruptured  by  a  foi-ce  that  does 
not  fracture  the  skull,  but  merely  leads  to  detach- 
ment of  the  dura  mater.  (See  page  29.)  Failing  this 
vessel,  the  most  frequent  source  of  extra-meningeal 
haemorrhage  is  the  lateral  sinus,  for  reasons  that  will 
be  obvious. 

With  regard  to  the  blood  sinuses  formed  by  the 
dura  mater,  nothing  remains  to  be  added  to  what  has 
been  already  said  (page  12),  except,  perhaps,  to 
observe  that  the  relations  between  the  internal 


Chap,  in.]  CRANIAL  CONTENTS.  31 

carotid  artery  and  cavernous  sinus  are  so  intimate 
that  arterio-venous  aneurism  has  followed  injury  in- 
volving these  parts.  It  will  be  seen  also  with  what 
ease  this  sinus  could  become  thrombosed  in  cases  of 
inflammation  within  the  orbit  by  the  extension  of  the 
mischief  along  its  great  tributaries,  the  two  ophthalmic 
veins. 

Sarcomatous  growths,  springing  from  the  dura 
mater  or  other  of  the  meninges,  may  make  their  way 
through  the  cranial  bones,  and  project  as  pulsating 
tumours  beneath  the  scalp.  Such  growths  are  included 
under  the  title  of  "  fungus  of  the  dura  mater." 

Between  the  dura  mater  and  the  arachnoid  is  the 
subdural  space,  formerly  known  as  the  "  cavity  of 
the  arachnoid."  According  to  Prescott  Hewett,  ex- 
travasations of  blood  after  injury  are  more  common 
in  this  space  than  in  any  other  part  within  the  skull. 
The  blood  so  poured  out  may  become  more  or  less 
discoloured,  and  present  in  time  the  aspect  of  a  thin 
and  peculiar  membrane  ;  or  the  collection  may  form 
itself  into  a  species  of  cyst  ("  arachnoid  cyst ")  that 
was  for  some  time  a  source  of  much  confusion  to 
pathologists. 

The  subdural  space  contains  a  small  amount  of 
fluid,  and  acts,  probably,  like  the  pleural  and  peri- 
toneal sacs  in  preventing  the  effects  of  friction  during 
the  movements  of  the  brain. 

The  sufoarachnoid  space  is  between  the  arach- 
noid and  the  pia  mater,  and  it  is  here  that  the  chief  part 
of  the  cerebro-spinal  fluid  is  lodged.  This  space  is  larger 
in  some  places  than  in  others.  It  is  insignificant  over 
the  convexity  of  the  brain,  but  is  very  extensive  at 
the  base  of  the  skull  in  the  parts  beneath  the  cere- 
bellum, the  medulla,  the  pons,  and  the  interpeduncular 
space  as  far  forwards  as  the  optic  nerves.  Thus  these 
very  important  parts  of  the  brain  do  not  rest  upon 
bone,  but  rest  rather  on  the  subarachnoid  collection 


32  SUXGTCAL  APPLIED  ANATOMY.     [Chap.  m. 

of  fluid  as  upon  a  water-bed,  to  use  a  comparison  of 
Mr.  Hilton's.  The  only  part  of  the  base  of  the  brain 
that  rests  directly  upon  bone  is  that  part  in  contact 
with  the  orbital  plates  and  lesser  wings  of  the  sphe- 
noid. The  posterior  two-thirds  of  the  brain  rests 
upon  the  "water-bed,"  and  is  thus  admirably  pro- 
tected. 

It  is  well  known  that  the  brain  may  be  damaged 
by  contre-coup.  That  is  to  say,  if  the  head  be  struck 
at  one  particular  part,  the  brain  may  be  found  unin- 
jured at  the  spot  struck,  but  damaged  at  a  correspond- 
ing place  on  the  opposite  side  of  the  skull.  The 
cerebro-spinal  fluid  is  much  concerned  in  modifying 
the  effects  of  contre-coup.  Thus,  if  the  vertex  be 
struck,  the  important  structures  at  the  base  of  the 
brain  would  be  in  the  greatest  clanger  of  being 
severely  injured,  did  they  lie  in  actual  contact  with 
the  bone.  Moreover,  when  a  blow  falls  upon  the 
occiput,  there  may  be  no  damage  to  the  brain  beneath 
the  spot  struck,  but  the  yielding  mass  is  thrown 
forward  within  the  skull,  and  were  it  not  for  the 
"  water-bed,"  the  under  parts  of  the  cerebrum  would 
be  torn  against  the  many  projections  in  the  base  of 
the  skull.  .  These  projections,  which  are  so  conspicuous 
in  the  dry  skull,  are  moulded  off  in  the  living  by  the 
dura  mater,  and  also  by  the  blood  sinuses  which  occupy 
the  hollows  about  these  projections,  and  also  certain 
margins  of  bone.  As  it  is,  the  only  part  that  usually 
suffers  is  the  under  surface  of  the  frontal  lobe  (a  com- 
paratively unimportant  segment),  which,  being  brought 
violently  in  contact  with  the  irregular  orbital  plate,  is 
readily  contused.  The  subarachnoid  space  commu- 
nicates with  the  ventricles  through  the  foramen  of 
Majendie.  This  foramen  leads  into  the  fourth  ven- 
tricle, and  is  an  aperture  in  the  pia  mater  that  closes 
in  that  ventricle.  From  the  fourth  ventricle  fluid 
can  pass  along  the  iter  into  the  third  ventricle,  and 


chap,  in.]  CRANIAL  CONTENTS.  33 

from  thence  to  the  lateral  ventricles  by  the  foramen  of 
Monro. 

The  cerebro-spinal  fluid  prevents  the  ill  effects  that 
irregularities  in  the  blood  circulation  might  have  upon 
the  brain,  situate  as  it  is  within  an  unyielding  cavity. 
If  the  great  nerve  centres  in  the  lateral  ventricles 
are  swollen  by  congestion,  they  are  not  met  by  an  un- 
yielding wall,  but  merely  displace  some  of  the  cerebro- 
spinal  fluid  through  the  foramen  of  Majendie,  until 
such  time  as  their  circulation  is  normal  again. 

Hilton  has  shown  that  closure  of  this  foramen 
may  lead  to  that  excessive  accumulation  of  fluid 
within  the  ventricles  known  as  hydrocephalus.  If  the 
brain,  too,  becomes  enlarged  by  congestion,  it  is  not 
met  by  unyielding  bone,  but  rather  by  an  adjustable 
water-bed,  and  during  its  period  of  enlargement  it 
merely  displaces  into  the  spinal  part  of  the  sub- 
arachnoid  space  some  of  the  fluid  that  surrounds  it. 
This  mutual  effect  is  well  illustrated  in  a  case  reported 
by  Hilton  of  a  man  with  a  fracture  of  the  base,  from 
whose  ear  cerebro-spinal  fluid  was  escaping.  The 
discharge  of  this  fluid  was  at  once  greatly  in- 
creased by  expiratory  efforts  when  the  nose  and 
mouth  were  held  closed,  and  the  veins  compressed 
in  the  neck. 

The  relations  of  the  brain  to  the  skull. — 
The  lower  level  of  the  brain  in  front  corresponds  to  a 
line  drawn  across  the  forehead  just  above  the  eye- 
brows. At  the  side  of  the  head  it  corresponds 
approximately  to  a  line  drawn  from  the  external 
angular  process  of  the  frontal  to  the  upper  part  of  the 
external  auditory  meatus.  A  line  drawn  from  this 
latter  spot  to  the  occipital  protuberance  corresponds 
to  the  lower  level  of  the  posterior  lobe,  while  below 
that  line  will  lie  the  cerebellum  (Fig.  7).  The  com- 
mencement of  the  Sylvian  fissure  corresponds  to  the 
pterion.  Its  ascending  limb  is  nearly  parallel  to,  and 


34 


SURGICAL  APPLIED  ANATOMY.     [Chap.  in. 


just   behind,    the   coronal    suture.      Its    posterior,  or 
horizontal    limb,   runs    backwards    across    the    upper 


Fig.  7.— Diagram  to  show  the  Relations  of  the  Brain  to  the  Skull. 
(Modified  from  Eeid.) 


margin  of  the  squamous  suture.    The  external  parieto- 
occipital  fissure  is  a  little   in  front  of  the  lambda. 


Chap,  in.]  CRANIAL  CONTENTS.  35 

The  fissure  of  Rolando  is  some  way  behind  the 
coronal  suture. 

The  temporo-sphenoidal  lobe  lies  almost  wholly 
below  a  line  drawn  horizontally  backwards  from  the 
external  angular  process.  The  upper  borders  of  the 
optic  thalamus  and  corpus  striatum  are  about  on  a 
level  with  the  top  of  the  pinna.  They  are  situate 
opposite  the  temporal  region,  and  the  anterior  limit 
of  the  corpus  striatum  about  corresponds  to  the 
pterion. 

The  following  more  detailed  account  of  the  topo- 
graphy of  the  brain  is  given  by  Dr.  Reid. 

The  base  line,  from  which  all  perpendicular 
lines  are  drawn,  runs  through  the  lowest  part  of  the 
infraorbital  margin  and  the  middle  of  the  external 
auditory  meatus. 

Longitudinal  fissure  of  cerebrum. — A  line  running 
along  the  median  line  of  the  top  of  the  head  from  the 
root  of  the  nose  to  the  occipital  protuberance. 

Transverse  fissure. — A  line  from  the  occipital 
protuberance  to  the  external  auditory  meatus. 

Fissure  of  Sylvius. — A  line  from  a  point  1£ 
inches  behind  the  external  angular  process  P  to  a 
point  f  of  an  inch  below  the  most  prominent  part  of  the 
parietal  eminence  x.  The  first  £  of  an  inch  of  the 
line  will  represent  the  main  fissure,  and  the  rest  of 
the  line  will  indicate  the  horizontal  limb.  The 
ascending  limb  will  start  from  the  posterior  end  of 
the  line  indicating  the  main  fissure,  and  run  vertically 
upwards  for  about  one  inch. 

Fissure  of  Rolando. — From  the  base  line  draw 
two  vertical  lines  upwards,  one  A  B  from  the  de- 
pression in  front  of  the  meatus,  and  another  c  D 
from  the  posterior  border  of  the  mastoid  process  at 
its  root.  There  is  thus  formed  a  four-sided  figure, 
bounded  above  and  belov  by  the  lines  of  the  longi- 
tudinal fissure  and  the  horizontal  limb  of  the  Sylvian 


36  SURGICAL  APPLIED  ANATOMY.     [Chap. in. 

fissure,  and  in  front  and  behind  by  the  two  vertical 
lines.  A  diagonal  line  D  E  drawn  from  the  posterior 
superior  angle  to  the  anterior  inferior  angle  of  the 
space  will  be  over  the  fissure  of  Rolando.  In  the 
adult,  the  upper  end  of  the  fissure  lies  half  an  inch 
behind  the  centre  of  the  median  line  of  the  head, 
measured  fi-om  the  root  of  the  nose  to  the  occipital 
protuberance  (Thane).  The  line  of  the  fissure  forms 
with  the  median  line  of  the  head  an  angle  of  about 
67°  (Hare). 

The  parieto-occipital  fissure  runs  outwards  and 
a  little  forwards  on  the  brain  for  about  one  inch. 
It  is  nearly  at  right  angles  to  the  longitudinal  fissure, 
and  lies  from  2  to  3  mm.  in  front  of  the  lambda 
(Horsley). 

Frontal  lobe.— A.  line  drawn  backwards  from 
the  supraorbital  notch  to  within  f  of  an  inch  of  the 
line  for  the  fissure  of  Rolando,  and  parallel  with  the 
longitudinal  fissure,  will  mark  the  superior  frontal 
sulcus.  The  frontal  part  of  the  temporal  ridge  will 
indicate  the  second  frontal  sulcus.  The  first,  second, 
and  third  frontal  convolutions  will  thus  be  mapped 
out.  The  ascending  frontal  convolution  will  occupy 
a  space  about  f  of  an  inch  broad,  parallel  with,  and 
in  front  of,  the  Rolandic  line. 

Parietal  lobe. — The  intraparietal  sulcus  commences 
near  the  horizontal  limb  of  the  Sylvian  fissure,  and 
ascends  midway  between  the  line  of  the  fissure  of 
Rolando  and  the  centre  of  the  parietal  eminence.  It 
reaches  a  point  below  the  horizontal  level  of  the 
superior  frontal  sulcus,  and  then  turns  backwards  to 
run  midway  between  the  longitudinal  fissure  and  the 
centre  of  the  parietal  eminence  (Horsley).  In  the 
space  above  this  sulcus  there  is  in  front,  parallel 
with  the  whole  length  of  the  fissui*e  of  Rolando,  the 
ascending  parietal  convolution,  and  behind  the 
superior  parietal  lobule.  The  space  below  the  sulcus 


Chap,  in.]  CRANIAL  CONTENTS.  37 

indicates  in  its  anterior  part  the  supramarginal 
convolution,  filling  up  the  most  prominent  part  of 
the  parietal  eminence,  and  in  its  posterior  part  the 
angular  gyrus. 

Temporo-sphenoidal  lobe. — Bounded  above  by  the 
line  of  the  Sylvian  fissure,  below  by  the  upper 
border  of  the  zygoma,  and  a  line  continued  back  from 
that  border  to  a  point  midway  between  the  occipital 
protuberance  and  the  posterior  border  of  the  mastoid 
at  its  root  G.  The  anterior  end  of  the  lobe  reaches  as 
far  as  the  posterior  superior  border  of  the  malar  bone. 
Its  posterior  end  is  bounded  by  a  line  (slightly  convex 
backwards)  drawn  from  the  posterior  end  of  the 
Sylvian  fissure  to  the  point  G.  A  line  running 
parallel  with  the  Sylvian  line,  and  one  inch  below  it, 
will  indicate  the  first  temporo-sphenoidal  sulcus,  and 
another  pai'allel  line,  three-quarters  of  an  inch  below 
again,  will  mark  the  second  temporo-sphenoidal  sulcus. 
The  superior,  middle,  and  inferior  temporo-sphenoidal 
convolutions  will  thus  be  mapped  out. 

The  occipital  lobe  occupies  the  remaining  sur- 
face of  the  scalp,  being  bounded  below  by  the  inner 
half  of  the  superior  curved  line,  and  in  front  by  the 
parieto-occipital  sulcus  and  the  temporo-sphenoidal 
lobe. 

The  cortical  centres  of  tlie  brain. — A  know- 
ledge of  the  position  of  these  centres  is  most  impor- 
tant in  enabling  certain  brain  lesions  to  be  localised, 
and  in  guiding  the  surgeon  in  opei-ations  upon  the 
cerebral  cortex.  The  precise  area  of  each  centre  has 
not  yet  been  very  accurately  defined,  and  the  exact 
limits  of  each  area  are  still  in  some  details  indefinite 
It  must  be  borne  in  mind  also  that  one  area  fuses 
with  another.  The  following  account  is  based  mainly 
upon  that  given  by  Dr.  Gowers. 

The  lower  limb. — The  posterior  part  of  the 
superior  frontal  convolution,  the  upper  parts  of  the 


38  SURGICAL  APPLIED  ANATOMY.     [Chap.  in. 

ascending  frontal  and  ascending  parietal  convolutions; 
the  upper  and  anterior  part  of  .the  superior  parietal 
lobule,  and  a  part  of  the  mesial  surface  of  the  brain 
(over  the  paracentral  lobule  and  a  part  of  the  quadrate 
lobe).  The  area  for  the  foot  lies  in  the  anterior  part 
of  the  district. 

The  upper  limb. — The  middle  third  of  the 
ascending  parietal  and  ascending  frontal  convolutions. 
The  shoulder  centre  lies  in  the  upper  part  of  the  area, 
the  elbow  lower  down,  and  the  hand  in  a  still  lower 
part  of  the  district. 

The  face. — The  upper  part  of  the  lower  third  of 
the  ascending  parietal  and  ascending  frontal  convolu- 
tions. The  centre  for  the  angle  of  the  mouth  is  in 
the  upper  segment  of  this  area. 

The  tongue  and  lips. — The  lowest  part  of  the 
ascending  frontal  convolution. 

The  area  of  motor  speech. — The  tongue  area  and 
adjacent  part  of  the  third  frontal  convolution. 

The  area  of  the  sense  of  hearing  occupies  the 
posterior  part  of  the  first  temporo-sphenoidal  con- 
volution. 

Of  the  brain  generally  little  has  to  be  said.  In 
a  surgical  sense,  it  presents  itself  simply  as  a  large 
mass  of  soft  tissue  that  may  be  damaged  by  shaking 
as  gelatine  may  be  shaken  in  a  case.  As  it  is  of  very 
yielding  structure,  and  does  not  entirely  fill  the 
cranial  cavity,  it  may,  as  it  were,  be  th-rown  about 
within  the  skull,  and  be  damaged  by  collision  with  its 
walls.  -Of  the  exact  mechanism  of  concussion  or 
shaking  of  the  brain  little  is  known,  and  it  cannot  be 
said  that  experiments,  such  as  those  of  M.  Gama, 
with  a  bulb  of  isinglass  within  a  glass  matrass,  tend  to 
throw  much  light  upon  the  subject.  In  contusion  or 
bruising  of  the  brain,  it  is  noticed  that  the  lesion  is 
very  much  more  frequently  situate  on  the  under  sur- 
face, both  as  regards  the  cerebrum  and  cerebellum, 


Chap.  III.] 


CRANIAL  CONTENTS. 


39 


than  on  any  other  part  (Prescott  Hewett).  To  this 
statement,  however,  there  is  the  striking  exception 
that  those  parts  of  the  base  of  the  cerebrum  that  rest 
upon  the  large  basal  collection  of  the  cerebro- spinal 
fluid  are  the  least  often  contused.  These  parts  include 
the  medulla,  the  pons,  and  the  interpedunculav  space. 


PO.F 


Fig.  8. — The  Motor  Centres  of  the  Cortex.     (Modifie  I  from  Gowers.) 

J||  Area  of  the  leg.  .•.-:.-  Area  of  motor  speech. 

Er=  Area  of  the  upper  limb.  •  • 

///  Area  of  the  face.  ++  Sensory  region,  area  of  hearing 

\\\  Area  of  the  tongue.  Otncr  markings  as  in  Fig.  7. 


The  brain  is  very  lavishly  supplied  with  blood- 
vessels. The  main  arterial  trunks  (vertebral  and 
internal  carotid)  are  both  rendered  tortuous  before 
entering  the  skull,  with  the  object  probably  of 
diminishing  the  effects  of  the  heart's  systole  upon  the 
brain.  On  entering,  they  are  almost  immediately 
blended  into  an  anastomosing  circle  (circle  of  Willis), 
which  has  the  effect  of  equalising  the  cerebral  circu- 
lation. Ligature  of  one  common  carotid  may  produce 
no  effect  upon  the  brain,  although  the  mortality  after 
this  operation  is  mainly  due  to  cerebral  complications- 


40  SURGICAL  APPLIED  ANATOMY.     [Chap.  in. 

One  carotid  and  the  two  vertebrals  would  appear  to  be 
able  to  bring  enough  blood  to  the  brain,  which  blood 
will  be  as  evenly  distributed  as  hitherto  by  the  circle 
of  Willis.  Both  common  carotids  have  been  ligatured, 
or  one  carotid  has  been  secured,  when  its  fellow  of  the 
opposite  side  has  been  occluded  by  disease,  and  no 
marked  cerebral  disturbances  have  followed.  In  HO 
case,  however,  has  the  patient  recovered  when  the 
interval  between  the  closing  of  the  two  vessels  was 
less  than  a  few  weeks.  The  vertebral  arteries  can 
carry  a  sufficient  amount  of  blood  to  the  brain  if  only 
the  strain  be  thrown  upon  them  gradually,  and  the 
brain  be  allowed  to  accommodate  itself  slowly  to  the 
change.  Plugging  of  any  of  the  smaller  cerebral 
arteries  by  emboli,  as  a  rule,  leads  at  once  to  a  marked 
disastrous  result.  Such  embolism  is  met  with  in 
surgery  in  connection  with  aneurism  of  the  common 
carotid.  In  simply  examining  such  aneurisms,  a 
little  piece  of  the  clot  contained  in  the  sac  has  been 
detached,  has  been  carried  up  into  the  brain,  and  has 
produced  a  plugging  of  one  of  the  cerebral  vessels. 
Thus,  hemiplegia  has  followed  upon  the  mere  exami- 
nation of  a  carotid  aneurism,  as  in  a  case  recorded 
by  Mr.  Teale,  of  Leeds.  Fergusson's  treatment  of 
aneurism  at  the  root  of  the  neck,  by  displacing  the 
clots  by  manipulation,  has  been  abandoned  on  this 
same  score.  In  the  second  case  treated  by  manipula- 
tion by  this  surgeon,  a  case  of  subclavian  aneurism, 
paralysis  of  the  left  side  of  the  body  followed  at  once 
upon  the  first  handling  of  the  tumour. 

The  pulsations  of  the  brain  may  be  communicated 
to  any  tumours  or  collections  of  fluid  that  reach  the 
surface  of  the  brain  through  an  aperture  in  the  skull. 
Such  pulsations  are  synchronous  with  the  arterial 
pulse,  but  the  sphygmographic  tracings  of  the  cerebral 
pulsation  exhibit  also  the  "respiratory  curve." 

Although   wounds  of  the   brain  bleed  freely,  the 


Chap,  iv.]  THE  ORBIT  AND  EYE.  4.1 

bleeding  is  checked  without  difficulty,  the  vessels 
being  capable  of  ready  contraction.  Large  tumours 
have  been  excised  from  the  cortex  of  the  brain, 
without  undue  trouble  from  haemorrhage. 


CHAPTER  IV. 

THE    ORBIT   AND    EYE. 

THE  orbit. — The  antero-posterior  diameter  of  the 
orbit  is  about  If  inches,  its  vertical  diameter  at  the 
base  a  little  over  \\  inches,  audits  horizontal  diameter 
at  the  base  about  \\  inches.  The  diameters  of  the 
globe  are  as  follows :  transverse,  24  mm.  ;  antero- 
posterior,  24-5  mm. ;  vertical,  23  mm.  (Brailey).  The 
eye-ball  is  therefore  nearer  to  the  upper  and  lower 
margins  of  the  orbit  than  it  is  to  the  sides,  and  the 
greatest  interval  between  the  globe  and  the  orbital 
wall  is  on  the  outer  side.  The  interior  of  the  orbit  is 
most  conveniently  reached  by  incisions  made  to  the 
outer  side  of  the  globe,  and,  in,  excision  of  the  eye- 
ball, the  scissors  are  usually  introduced  on  that  side 
when  the  optic  nerve  has  to  be  divided.  In  excising 
the  left  eye,  however,  it  may  be  more  convenient  to 
divide  the  optic  nerve  from  the  inner  side.  The 
bones  forming  the  floor,  the  roof,  and  the  inner  wall  of 
the  orbital  cavity,  are  very  thin,  especially  in  the  last- 
named  situation.  Thus,  foreign  bodies  thrust  into 
the  orbit  have  readily  penetrated  into  the  cranial 
cavity,  into  the  nose  and  ethrnoidal  cells,  and,  when 
directed  from  above,  into  the  antrum.  In  sevei'al 
instances,  a  sharp  pointed  substance,  such  as  the  end 
of  a  stick  or  foil,  has  been  thrust  into  the  brain 
through  the  orbit,  and  has  left  but  little  external 
evidence  of  this  serious  lesion.  Nelaton  mentions  a 


42  SURGICAL  APPLIED  ANATOMY.     [Chap.  iv. 

case  in  which  the  internal  carotid  artery  was  wounded 
through  the  orbit.  Certain  cases  of  pulsating  orbital 
tumour  which  depend  upon  a  communication  between 
the  carotid  artery  and  the  cavernous  sinus  have  a 
traumatic  origin. 

A  reference  to  the  relations  of  the  orbital  walls  will 
show  that  a  tumour  may  readily  invade  the  orbit  by 
spreading  from  (1)  the  base  of  the  skull,  (2)  from  the 
nasal  fossoe,  (3)  from  the  antrum,  ami  (4)  from  the 
temporal  or  zygomatic  fossae.  In  any  of  these  instances 
the  growth  may  enter  the  orbit  by  destroying  the 
intervening  thin  layers  of  bone,  and,  in  tumours  of 
the  antrum,  this  is  the  usual  mode  of  entry.  It 
may,  however,  extend  more  readily  from  the  cranial 
cavity  through  the  optic  foramen  or  spheiioidal  fissure, 
from  the  nose  through  the  nasal  duct,  and  from  the 
two  fossae  named  through  the  spheno-maxillary  fissure. 
After  violent  blows  upon  the  temple  blood  has  found 
its  way  into  the  orbit  through  the  spheno-maxillary 
fissure,  and  has  led  to  subconjunctival  ecchymosis. 
Distension  of  the  frontal  sinus  by  retained  mucus  or 
pus  may  lead  to  a  prominent  tumour  at  the  upper  and 
inner  margin  of  the  orbit,  above  the  level  of  the 
tendo  oculi,  which  may  cause-  displacement  of  the 
globe  downwards,  outwards,  and  forwards.  The  bones 
of  the  orbit  are  peculiarly  apt  to  be  the  seat  of  ivory 
exostoses,  which  may  in  time  entirely  occupy  the  orbital 
cavity.  At  the  upper  and  outer  angle  of  the  orbit  a 
congenital  sebaceous  cyst  is  sometimes  met  with.  It 
lies  beneath  the  orbicularis  muscle,  and  is  often  con- 
nected at  some  depth  with  the  orbital  periosteum. 

The  capsule  of  Tenon. — The  best  description 
of  this  capsule  has  been  given  by  Mr.  Lockwood ;  of 
his  researches  Prof.  Cunningham  provides  the  follow- 
ing resume  : 

The  capsule  is  a  firm  loose  membrane  spread  over 
the  posterior  fths  of  the  globe,  the  cornea  alone  being 


chap,  iv.i  THE  ORBIT  AND  EYE,  43 

free  from  it.  In  front  it  lies  under  the  ocular  con- 
junctiva, with  which  it  is  intimately  connected,  and  it 
ends  by  blending  with  that  membrane  close  to  the 
margin  of  the  cornea.  Behind  it  fuses  with  the  sheath 
of  the  optic  nerve,  where  the  latter  pierces  the 
sclerotic.  The  surface  of  the  membrane  towards  the 
globe  is  smooth,  and  is  connected  to  the  eye-ball  by 
some  soft  yielding  areolar  tissue.  It  thus  forms  a 
kind  of  dome  for  the  globe,  a  species  of  socket  in 
which  it  moves.  The  posterior  surface  of  the  capsule 
is  in  contact  with  the  orbital  fat.  The  tendons  of  the 
ocular  muscles  pierce  the  capsule  opposite  the  equator 
of  the  globe.  The  lips  of  the  openings  through  which 
the  four  recti  pass  are  prolonged  backwards  upon  the 
muscles,  in  the  form  of  sheaths,  very  much  as  the 
inf undibuliform  fascia  is  prolonged  upon  the  cord  from 
the  internal  abdominal  ring.  Mr.  Lockwood  points 
out  that  each  of  these  four  apertures  is  strengthened 
by  a  vertical  slip  of  fibrous  tissue,  the  intracapsular 
ligament.  As  the  capsule  is  fixed  at  various  points  to 
the  wall  of  the  orbit,  these  ligaments  act  as  pulleys, 
and  protect  the  globe  from  pressure  during  contrac- 
tion of  the  muscles.  When  the  insertions  of  the 
recti  muscles  are  divided  in  cases  of  strabismus,  the 
capsule  is  distinctly  seen  after  the  conjunctiva  has 
been  cut  through,  and  requires  also  to  be  divided 
before  the  section  of  the  muscle  can  be  properly  made. 
The  capsule  is  of  some  importance  in  this  procedure. 
After  its  division,  the  muscle  does  not  entirely 
retract  and  lie  shrunken  within  the  orbit.  Its  con- 
nections with  the  capsule  still  give  it  some  hold  upon 
the  globe,  and  still  enable  it  to  act  \ipon  that  struc- 
ture. Moreover,  the  attachments  of  the  capsule  to 
the  margins  of  the  orbit  prevent  the  muscles  from 
entirely  retracting,  and,  even  when  the  globe  has  been 
removed,  they  give  them  some  basis  to  act  upon,  and 
thus  tend  to  preserve  some  little  mobility  in  the  stump. 


44  SURGICAL  APPLIED  ANATOMY.     ichar.  iv 

Of  these  orbital  attachments  the  suspensory 
ligament  of  Lockwood  is  the  most  important.  It 
stretches  across  the  fore  part  of  the  orbit  after  the 
fashion  of  a  hammock,  and  supports  the  eye-ball.  Its 
two  extremities  are  attached  respectively  to  the 
malar  and  lachrymal  bones.  Below  the  eye-ball  it 
widens  out,  and  blends  with  the  capsule  of  Tenon. 
Strong  bands  pass  from  the  sheaths  of  the  external  and 
internal  recti  muscles  to  the  malar  and  lachrymal 
bones  respectively.  They  limit  excessive  rotation  of 
the  globe  in  an  outward  or  inward  direction.  The 
action  of  the  superior  rectus  is  checked  by  its  connec- 
tion with  the  levator  palpebrte,  and  that  of  the  inferior 
rectus  by  the  connection  of  its  tendon  with  the 
suspensory  ligament. 

Mr.  Lockwood  points  out  that  in  removing  the 
upper  jaw  the  surgeon  should  take  care  to  preserve 
the  attachments  of  the  suspensory  ligament.  If 
these  be  destroyed  the  eye-ball  sinks  downwards. 

The  orbit  behind  Tenon's  fascia  is  occupied  by  a 
large  quantity  of  loose  fat,  in  addition  to  the  ocular 
muscles,  the  vessels,  and  nerves.  It  is  by  the  absorp- 
tion of  this  fat  that  the  sunken  eye  is  produced  in 
cases  of  emaciation  and  prolonged  illness.  This 
tissue  affords  a  ready  means  for  the  spread  of  oa-bital 
abscess.  Such  an  abscess  may  follow  injuries, 
certain  ocular  inflammations,  periostitis,  etc.,  or  may 
spread  from  adjacent  parts.  The  pus  may  occupy  the 
entire  cavity,  displacing  the  eye-ball  forwards,  limit- 
ing its  movements,  and  causing,  by  interference  with 
the  circulation,  great  redness  of  the  conjunctiva  and 
swelling  of  the  lids. 

Foreign  bodies,  some  of  them  of  remarkable  size 
and  shape,  have  lodged  for  long  periods  of  time  in 
the  orbital  fat  without  causing  much  trouble.  Thus 
Lawson  reports  a  case  where  a  piece  of  an  iron 
hat-peg,  three  inches  long,  was  embedded  in  the 


chap,  i v.i  THE  ORBIT  AND  EYE.  45 

orbit  for  several  days  without  the  patient  being 
aware  of  it.  A  stranger  case,  ia  some  ways,  is  that 
reported  by  Furneaux  Jordan :  "  A  man,  who  was 
employed  in  threshing,  became  the  subject  of  severe 
ophthalmia.  At  the  expiration  of  several  weeks,  the 
patient,  whilst  pressing  his  finger  on  the  lower  eyelid, 
suddenly  ejected  from  a  comfortable  bed  of  warm  pus 
a  grain,  of  wheat,  which  had  shot  forth  a  vigorous 
green  sprout."  Tho  orbital  fat  affords  also  an  excel- 
lent nidus  for  growing  tumours.  Fractures  of  the 
inner  wall  of  the  orbit  involving  the  nasal  fossga  or 
sinuses,  may  lead  to  extensive  emphysema  of  the  orbital 
cellular  tissue.  The  air  so  introduced  may  cause  the 
globe  to  protrude,  may  limit  its  movements,  may 
spread  to  the  lids,  and  will,  in  any  case,  be  increased 
in  amount  by  blowing  the  nose,  etc. 

The  orbital  muscles. — The  four  recti  muscles 
end  in  thin,  flat  membranous  tendons.  The  tendon 
of  the  external  or  internal  rectus  muscle  is  frequently 
divided  for  strabismus.  The  width  of  the  tendons 
varies  from  7  mm.  to  9  mm.  They  are  inserted  into 
the  sclerotic  near  the  cornea.  The  internal  rectus  is 
inserted  6'5  mm.  from  the  corneal  margin,  the  ex- 
ternal 6 '8  mm.,  the  inferior  7 '2  mm.,  and  the  superior 
8  mm.  (Merkel). 

The  external  and  inferior  recti  are  the  longest, 
the  internal  rectus  is  the  broadest,  and  the  superior  ia 
the  narrowest  and  slightest. 

The  orbital  arteries  are  small,  and  seldom  give 
rise  to  trouble  when  divided  in  excising  the  globe, 
since  they  can  be  readily  compressed  against  the  bony 
walls  of  the  cavity.  Pulsating  tumours  of  this  part, 
may  be  due  to  traumatic  aneurisms  of  one  of  the 
orbital  arteries,  or  may  depend  upon  an  arterio- venous 
aneurism  formed  between  the  internal  carotid  artery 
and  the  cavernous  sinus.  Pressure  also  upon  the 
ophthalmic  vein  (as  it  enters  the  sinus),  by  an  aneurism 


46  SURGICAL  APPLIED  ANA  TO  MY.     [Chap.  iv. 

of  the  internal  carotid  vessel,  may  produce  all  the 
symptoms  associated  with  pulsating  orbital  tumours. 

The  orbital  nerves  may  be  damaged  in  wounds 
of  the  orbit,  or  in  fractures  of  the  orbit  and  of  the 
base  of  the  skull.  They  may  be  pressed  upon  by 
tumours  from  various  parts,  by  aneurisms,  hsemorr- 
hagic  and  inflammatory  effusions.  Thus  Lawson  re- 
cords a  case  in  which  the  optic  nerve  was  divided  by  a 
stab  through  the  upper  eyelid,  without  the  globe  being 
injured,  and  without  any  bone  being  fractured.  Tho 
same  nerve  has  also  been  completely  torn  across  in 
fractures  of  the  orbit,  and  has  been  pressed  upon  in 
fractures  involving  the  lesser  wing  of  the  sphenoid. 
The  third,  fourth,  and  sixth  nerves,  and  the  first  divi- 
sion of  the  fifth,  may  be  affected  in  cases  of  aneurism 
involving  the  internal  carotid  artery,  where  they  lie  in 
relation  with  the  cavernous  sinus.  They  may  readily 
be  pressed  upon,  also,  by  any  growth  involving  the 
sphenoidal  fissure,  such  as  a  periosteal  node  springing 
from  the  margin  of  the  fissure,  while  the  sixth  nerve, 
from  its  more  intimate  connection  with  the  base  of  the 
skull,  has  been  directly  torn  across  in  a  fracture  in- 
volving that  part  (Prescott  Hewett). 

In  paralysis  of  the  third  nerve  there  is 
drooping  of  the  upper  lid  (ptosis) ;  the  eye  is  almost 
motionless,  presents  a  divergent  squint  form  unop- 
posed action  of  the  external  rectus  muscle,  and  cannot 
be  moved  either  inwards,  upwards,  or  directly  down- 
wards. Rotation,  in  a  direction  downwards  and  out- 
wards, can  still  be  effected  by  the  superior  oblique  and 
outer  rectus  muscles.  The  pupil  is  dilated  and  fixed ; 
the  power  of  accommodation  is  much  impaired,  there 
is  diplopia,  and  sometimes  a  little  protrusion  of  the 
globe  from  relaxation  of  the  recti  muscles.  These 
symptoms  refer  to  complete  paralysis  of  the  nerve. 
In  cases  of  partial  paralysis,  only  one  or  two  of  the 
above  symptoms  may  be  present. 


Chap,  iv.j  THE  ORBIT  AND  EYE.  47 

In  paralysis  of  the  fourth  nerve  there  is  often 
but  little  change  to  be  seen,  since  the  function  of  the 
superior  oblique  muscle,  supplied  by  this  nerve,  may, 
in  part,  be  performed  vicariously.  "  There  is  usually 
only  very  slight  defect  in  the  mobility  of  the  eye  \ 
what  there  is  occurs  chiefly  in  the  inner  and  lower 
angle  of  the  field  of  vision ;  there  is  deviation  of  the 
eye  inwards  and  upwards  on  lowering  the  object, 
and  simply  upwards  when  it  is  turned  far  towards 
the  healthy  side  "  (Erb).  In  any  case  there  will  be 
diplopia,  especially  in  certain  positions  of  the  globe. 

In  paralysis  of  the  sixth  nerve  there  is  con- 
vergent strabismus,  with  consequent  diplopia,  and  an 
inability  to  rotate  the  eye  directly  outwards. 

Sometimes  all  the  oculo -motor  nerves  of  the  eye 
are  paralysed,  and  in  such  cases  the  lesion  is  probably 
situated  either  at  their  nuclei  of  origin  or  at  the 
cavernous  sinus,  in  the  wall  of  which  the  nerves  lie 
close  together. 

In  paralysis  of  the  first  division  of  the  fifth 
there  is  a  loss  of  sensation  in  all  the  conjunctiva,  except 
such  as  covers  the  lower  lid  (supplied  by  the  palpebral 
bi'anch  of  the  infraorbital  nerve),  loss  of  sensation  in 
the  globe,  and  in  the  skin  supplied  by  the  supratrochlear 
and  supraorbital  nerves,  and  in  the  mucous  and  cuta- 
neous surfaces  supplied  by  the  nasal  nerve.  No  reflex 
movements  (winking)  follow  upon  irritation  of  the 
conjunctiva,  although  the  patient  can  be  made  to  wink 
on  exposing  the  eye  to  a  strong  light,  the  optic  nerve 
in  this  case  transmitting  the  impression  to  the  facial 
nerve.  Sneezing  also  cannot  be  excited  by  irritating 
the  mucous  membrane  in  the  anterior  part  of  the  nose. 
Destructive  ulceration  of  the  cornea  may  follow  thi.s 
paralysis,  due  partly  to  damage  to  the  trophic  branches 
contained  in  the  paralysed  nerve,  partly  to  the  anaes- 
thesia which  renders  the  part  readily  injured,  and 
partly  to  the  loss  of  the  reflex  effect  of  the  sensory 


48  SURGICAL  APPLIED  ANATOMY.      [Chap. iv. 

nerves  upon  the  calibre  of  the  blood-vessels,  whereby 
the  inflammation  is  permitted  to  go  uncontrolled 
(Nettleship). 

In  paralysis  of  the  cervical  sympathetic 

there  is  narrowing  of  the  palpebral  fissure  from 
some  drooping  of  the  upper  lid,  apparent  recession 
of  the  globe  within  the  orbit,  and  some  narrow- 
ing of  the  pupil  from  paralysis  of  the  dilator 
muscle  of  the  iris,  which  muscle  is  supplied  by  the 
sympathetic.  The  drooping  of  the  upper  lid  may  be 
explained  by  the  fact  that  each  eyelid  contains  a  layer 
of  unstriated  muscle  fibre.  That  in  the  upper  lid  arises 
from  the  under  surface  of  the  levator  palpebrse,  and 
is  attached  to  the  tarsal  cartilage  near  its  upper  mar- 
gin (Fig.  11).  This  layer  of  muscle,  which,  when  in 
action',  would  keep  up  the  lid,  is  under  the  influence  of 
the  cervical  sympathetic.  The  recession  of  the  globe 
is  supposed  by  some  to  be  due  to  paralysis  of  the 
orbitalis  muscle  of  H.  Miiller.  This  muscle  bridges 
over  the  spheno-maxillary  fissure,  is  composed  of 
unstriated  fibres,  and  is  innervated  by  the  sympathetic. 
Contraction  of  the  muscle  (as  produced  by  irritation 
of  the  cervical  sympathetic  in  animals)  causes  pro- 
trusion of  the  globe,  while  section  of  the  sympathetic 
in  the  neck  produces  retraction  of  the  eye-ball  (01. 
Bernard).  No  changes  are  observed  in  the  calibre 
of  the  blood-vessels  of  the  globe. 

The  globe;  the  cornea. — The  thickness  of  the 
cornea  varies  from  9  mm.  in  the  central  parts  to  1  •!  mm. 
at  the  periphery.  One  is  apt  to  be  a  little  deceived  as 
to  its  thickness,  and  on  introducing  a  knife  into  the 
cornea,  the  instrument,  if  not  entered  at  the  proper 
angle,  may  be  thrust  for  some  little  distance  among 
the  laminae  of  the  part.  In  front  the  cornea  is  covered 
by  stratified  epithelium.  When  this  layer  has  been 
removed  by  abrasion,  a  white  deposit  of  lead  salts  may 
take  place  in  the  exposed  cornea!  tissue  in  cases  where 


Chap.  IV.] 


THE  ORBIT  AND 


49 


lead  lotions  are  used.  The  bulk  of  the  cornea  is  made 
up  of  a  great  number  of  fibrous  lamellae,  between 
which  are  anastomosing  cell  spaces  containing  the 
corneal  corpuscles.  If  the  nozzle  of  a  fine  syringe 
be  thrust  into  the  corneal  tissue,  the  network  of  cell 
spaces  can  be  tilled  with  injection  (Recklinghausen's 
canals).  When  suppuration  takes  place  within  the 


3 


Fig.  9.— A  Horizontal  Section  of  the  Globe  through  the  middle. 

a.  Cornea  ;  b,  sclerotic ;  c,  choroid  ;  rf,  retina  ;  e,  lens  ;  /,  iris ;  g,  ciliary  process  ; 
ft,  canal  of  Scnlemm. 

proper  corneal  tissue,  it  is  probably  along  these  canals, 
modified  by  inflammation,  that  the  pus  spreads,  thus 
producing  onyx.  The  cornea  contains  no  trace  of 
blood-vessels,  except  at  its  extreme  periphery,  where 
the  capillaries  of  the  sclerotic  and  conjunctiva  end  in 
loops.  This  lack  of  a  direct  blood  supply  renders 
the  cornea  prone  to  inflame  spontaneously  in  the 
cachectic  and  ill-nourished.  When  inflamed,  the  tissue 
always  becomes  opaque.  In  the  affection  known  as 
"E— 4 


50  SURGICAL  APPLIED  ANATOMY.      [Chap.  iv. 

interstitial  keratitis,  blood-vessels  from  the  arteries  at 
the  margin  of  the  cornea  penetrate  into  the  substance 
of  the  cornea  for  some  distance.  As  these  vessels  will 
be  some  little  way  below  the  surface,  and  will  be  covered 
by  the  hazy  cornea!  tissue  that  is  the  result  of  the 
disease,  their  scarlet  colour  is  much  toned  down,  and 
a  strand  of  such  vessels  is  called  a  "  salmon  patch." 
In  the  condition  known  as  pannus,  the  cornea 
appears  to  be  vascularised  ;  but  here,  owing  to  con- 
tinued irritation,  vessels,  derived  from  the  neighbour- 
ing conjunctival  arteries,  pass  over  the  cornea  just 
beneath  its  epithelial  covering,  leaving  the  cornea 
proper  as  bloodless  as  ever.  The  term  arcus  senilis  is 
applied  to  two  narrow  white  crescents  that  appear  at 
the  periphery  of  the  cornea,  just  within  its  margin,  in 
the  aged,  and  in  certain  morbid  conditions.  The 
crescents  are  placed  at  the  upper  and  lower  margins, 
and  their  points  meet  midway  on  either  side  of  the 
cornea.  They  are  due  to  fatty  degeneration  of  the 
corneal  tissue,  and  the  change  is  most  marked  in  the 
layers  of  the  cornea  just  beneath  the  anterior  elastic 
lamina,  i.e.  in  the  pai't  most  influenced  by  the  marginal 
blood-vessels.  In  spite  of  its  lack  of  a  direct  blood 
supply,  wounds  of  the  cornea  heal  kindly.  The  cornea 
is  very  lavishly  supplied  with  nerves,  estimated  to 
be  from  forty  to  forty-five  in  number.  They  are 
derived  from  the  ciliary  nerves,  enter  the  cornea 
through  the  fore  part  of  the  sclerotic,  and  are  dis- 
tributed to  every  part  of  the  tunic.  In  glaucoma, 
a  disease,  the  phenomena  of  which  depend  upon  greatly 
increased  intraocular  pressure,  the  cornea  becomes 
anaesthetic.  This  depends  upon  the  pressure  to  which 
the  ciliary  nerves  are  exposed  before  their  branches 
reach  the  cornea.  (See  also  Nerve  supply  of  the  eye- 
ball, page  55.) 

The  sclerotic,  choroid,  and  iris.— The  sclerotic 
is  thickest   behind,  and   thinnest  about  a  quarter  of 


chap,  iv.]  THE  ORBIT  AND  EYE.  51 

an  inch  from  the  cornea.  When  the  globe  is  ruptured 
by  violence  it  is  the  sclerotic  that  most  commonly 
yields,  the  rent  being  most  usually  a  little  way  from 
the  cornea,  i.e.  in  or  about  the  thinnest  part  of  the 
tuiiic.  A  rupture  of  the  cornea  alone  from  violence 
is  not  common.  The  sclerotic  may  be  ruptured  while 
the  lax  conjunctiva  over  it  remains  untorn.  In  such 
a  case  the  lens  may  escape  through  the  rent  in  the 
sclerotic,  and  be  found  under  the  conjunctiva.  At 
the  point  of  penetration  of  the  optic  nerve  the  sclerotic 
is  thin,  and  pierced  by  numerous  holes  for  the  passage 
of  nerve  bundles.  This  weakened  part,  the  lamina 
cribrosa,  plays  an  important  part  in  glaucoma  (page 
63).  It  gives  the  stippled  appearance  to  the  optic 
papilla.  Brailey  states  that  the  lateral  parts  of  the 
sclerotic  are  thinner  than  the  upper  and  lower 
segments,  the  inferior  part  being  the  thickest  and 
the  external  wall  the  thinnest.  It  happens,  therefore, 
that  under  the  influence  of  intraocular  pressure  the 
eye  expands  more  laterally  than  in  the  vertical  direc- 
tion. It  is  mainly  to  the  denseness  and  unyielding 
character  of  the  sclerotic  that  must  be  ascribed  the 
severe  pain  (due  to  pressure  on  nerves)  experienced 
in  those  eye  affections  associated  with  increased  intra- 
ocular tension  (glaucoma,  etc.).  The  choroid  is  the 
vascular  tunic  of  the  globe,  and  carries  its  main  blood- 
vessels. Between  the  choroid  and  sclerotic  are  two 
thin  membranes,  the  lamina  suprachoroidea  and  lamina 
fusca,  which  are  separated  from  one  another  by  a 
lymph  space.  In  injuries  to  the  globe,  therefore,  ex- 
tensive bleeding  may  take  place  between  these  two 
coats,  and  indeed  a  like  haemorrhage  may  be  the  result 
simply  of  a  sudden  diminution  in  the  ocular  tension 
produced  by  such  an  operation  as  iridectomy  or  cata- 
ract extraction.  The  choroid  alone  has  been  ruptured 
(usually  at  its  posterior  part)  as  the  result  of  a  blow 
upon  the  front  of  the  eye.  The  choroid  is  one  of  the 


52  SURGICAL  APPLIED  ANATOMY.      [Chap.  iv. 

few  parts  of  the  body  that  may  be  the  seat  of  mela- 
notic  growths.  These  growths  are  sarcomatous  tumours 
containing  a  large  amount  of  pigment,  and  occur  only 
where  pigment  cells  are  found.  In  the  choroid  coat 
pigment  cells  are  very  abundant.  The  iris  is,  from 
its  great  vascularity,  very  easily  inflamed.  From  its 
relations  to  the  cornea  and  sclerotic  it  happens  that 
inflammation  in  those  tunics  can  spread  without 
difficulty  to  the  iris.  On  the  other  hand,  the  vessels 
of  the  iris  and  choroid  are  so  intimately  related  that 
inflammations  set  up  in  the  iris  itself  have  every  in- 
ducement to  spread  to  the  choroidal  tuuic.  When 
the  iris  is  inflamed  its  colour  becomes  altered,  owing 
to  the  congestion  of  the  part  and  to  the  effusion  of 
lymph  and  serum  that  takes  place  in  its  substance. 
The  swelling  to  which  it  becomes  subject,  together 
with  the  effusion,  produce  a  blurring  of  its  delicate 
reticulated  structure,  as  seen  through  the  cornea. 
Owing  also  to  the  swollen  condition  of  the  little  mem- 
brane, the  pupil  becomes  encroached  on,  and  appears 
to  be  contracted,  while  the  movements  of  the  mem- 
brane are  necessarily  rendered  very  sluggish.  If  it  be 
remembered  that  the  greater  part  of  the  posterior 
surface  of  the  iris  is  in  actual  contact  with  the  lens 
capsule,  it  will  be  understood  that  inflammatory  ad- 
hesions may  readily  take  place  between  the  two  parts 
(Mg.  10).  After  iritis,  therefore,  it  is  common  to  find 
the  posterior  surface  of  the  iris  (most  often  its 
pupillary  margin)  adherent  to  the  lens  capsule  by 
bands  of  lymph,  either  entirely  or  in  one  or  more 
different  points.  Such  adhesions  constitute  posterior 
synechiae,  the  term  anterior  synechia?  being  applied  to 
adhesions  between  the  iris  and  the  cornea.  In  iritis 
also  the  lens  may  become  involved,  and  the  condition 
of  secondary  or  inflammatory  cataract  be  produced. 
The  iris  is  not  very  closely  attached  at  its  insertion. 
Thus,  in  cases  of  injury  to  the  eye,  it  may  be  torn 


chap,  iv.]  THE  ORBIT  AND  EYE.  53 

more  or  less  from  its  attachments  without  any  damage 
being  done  to  the  other  tunics.  The  iris  has  been 
completely  torn  away  in  a  few  instances,  and  has 
escaped  through  a  wound  of  the  globe.  The  ciliary 
processes  have  been  thus  exposed.  Congenital  absence 
of  the  iris  has  been  recorded.  In  cases  of  penetrating 
wounds  of  the  cornea  the  iris  is  easily  prolapsed. 
It  is  so  delicate  and  yielding  a  membrane,  that  in  per- 
forming iridectomy  the  necessary  piece  of  the  iris  can 
be  seized  and  pulled  out  through  the  corneal  incision 
without  offering  sensible  resistance.  The  membrane 
also  derives  much  support  from  its  contact  with  the 
lens,  for  in  cases  where  the  lens  has  been  displaced 
into  the  vitreous  or  has  been  removed  by  operation, 
the  iris  is  observed  to  be  tremulous  when  the  globe  is 
moved.  Although  very  vascular,  the  iris  seldom 
bleeds  much  when  cut,  a  circumstance  that  is  pro- 
bably due  to  the  contraction  of  the  muscular  fibres 
that  exist  so  plentifully  within  it.  Sometimes  the 
iris  presents  a  congenital  gap  in  its  substance  that 
runs  from  the  pupil  downwards  and  a  little  inwards. 
This  condition  is  known  as  coloboma  iridis,  and  is  due 
to  the  persistence  of  the  "choroidal  cleft."  In  other 
cases  there  can  be  seen,  stretching  across  the  pupil, 
some  shreds  of  the  pupillary  membrane.  Normally 
this  membrane,  which  is  apparent  for  a  few  days  after 
birth  in  some  animals,  is  entirely  absorbed  before  birth. 

It  will  now  be  convenient  to  take  note  of  the 
blood  and  nerve  supply  of  the  globe. 

Blood  supply  of  the  eye-ball. — 1.  The  short 
ciliary  arteries  (from  the  ophthalmic)  pierce  the  sclerotic 
close  to  the  optic  nerve,  run  some  little  way  in  the 
outer  coat  of  the  choroid,  and  then  break  up  into  a 
capillary  plexus  that  makes  up  the  main  part  of  the 
inner  choroidal  coat.  In  front  this  plexus  gives  some 
vessels  to  the  ciliary  processes.  The  veins  from  these 
vessels  are  disposed  in  curves  as  they  converge  to  four 


54  SURGICAL  APPLIED  ANATOMY.      [Chap.  iv. 

or  five  main  trunks  (venoe  vorticosse),  which  pierce  the 
sclerotic  midway  between  the  cornea  and  the  optic 
nerve.  In  the  choroid  they  lie  external  to  the 
arteries. 

2.  The    two     long     ciliary    arteries    (from    the 
ophthalmic)    pierce   the   sclerotic    to    the    outer   side 
of  the  optic  nerve,  and  run  forwards,  one  on  either 
side,  until  they  reach  the   ciliary  region,  where  they 
break  up  into  branches  that,  by  anastomosing,  form  a 
vascular  circle  about  the  periphery  of    the  iris  (the 
circulus  major).     From  this  circle  some  branches  pass 
to  the  ciliary  muscle,  while  the  rest  run  in  the  iris  in 
a  converging  manner  towards  the  pupil,  and  at  the 
margin  of  the  pupil  form  a  second  circle  (the  circulus 
minor). 

3.  The  anterior  ciliary  arteries  (from  the  muscular 
and   lachrymal    branches   of   the    ophthalmic)    pierce 
the    sclerotic    (perforating    branches)    about    a    line 
behind  the  cornea,  join  the  circulus  major,  and  give  off 
branches   to   the    ciliary   processes,  where  they  form 
copious  anastomosing  loops.     These  arteries  lie  in  the 
subconjunctival  tissue.      Their  episcleral,  or  iion-per- 
forating  branches,  are  very  small  and  numerous,  and 
are   invisible  in   the   normal   state   </  the  eye.     In 
inflammation,  however,  of  the  iris  and  adjacent  parts, 
these  vessels  appear  as  a  narrow  pink   zone  of  fine 
vessels   round   the    margin   of    the    cornea,  that  run 
nearly   parallel  to  one  another,  are  very  closely  set, 
and  do  not  move  with  the  conjunctiva.     This  zone  is 
known  as  the  zone  of  ciliary  congestion,  or  the  circum- 
corneal  zone. 

4.  The  vessels  of  the  conjunctiva  are  derived  from 
the  lachrymal    and    two    palpebral    arteries.       These 
vessels,    in   cases   of   inflammation,    are    readily    dis- 
tinguished from  those  last  described.     They   are  of 
comparatively  large  size,  are  tortuous,  are  of  a  bright 
brick-red    colour,    can    be     easily    moved    with    the 


Chap,  iv.i  THE  ORBIT  AND  EYE.  55 

conjunctiva,  and  as  easily  emptied  of  their  blood  by 
pressure.  The  differences  presented  by  these  two 
sets  of  vessels  serve  in  one  way  to  distinguish  in- 
flammation of  the  conjunctiva  from  that  involving 
deeper  parts.  The  conjunctival  vessels  around  the 
margin  of  the  cornea  form  a  closer  plexus  of  anasto- 
mosing capillary  loops,  which  become  congested  in 
severe  superficial  inflammation  of  the  cornea,  and 
may  then  form  a  zone  around  the  margin  of  the 
cornea,  which  can,  however,  be  distinguished  from 
the  "  ciliary  zone "  by  the  general  characters  just 
named.  The  retina  has  a  vascular  system  of  its  own, 
supplied  through  the  arteria  centralis  retince,  which  is 
nowhere  in  direct  communication  with  the  choroidal 
vessels,  except  just  at  the  entrance  of  the  optic  nerve. 
Indeed,  the  outer  layers  of  the  retina  which  are  in 
relation  with  the  choroid  coat  are  entirely  destitute  of 
vessels.  Thus,  when  the  central  artery  of  the  retina 
becomes  plugged,  sudden  blindness  follows,  and  as  the 
meagre  collateral  circulation  that  is  established  by  the 
minute  anastomoses  about  the  entrance  of  the  nerve 
is  quite  insufficient,  the  retina  soon  becomes  cedema- 
tous  and  inflamed.  A  permanent  plugging  of  the 
central  artery  means,  thei-efore,  a  practical  extinction 
of  the  vascular  system  of  the  retina.  In  some  cases 
of  embolism  only  a  branch  of  the  retinal  artery  is 
plugged,  the  patient  retaining  vision  except  in  that 
part  of  the  retina  supplied  by  the  branch. 

In  cases  of  haemorrhage  between  the  choroid  and 
retina  the  blood  must  come  from  the  choroidal  vessels; 
and  in  haemorrhage  into  the  vitreous,  which  often 
follows  injury,  the  blood  may  be  derived  from  the 
retinal  vessels,  since  they  run  in  the  inner  layers  of 
that  membrane,  or  from  the  vessels  in  the  ciliary 
region. 

Nerve  supply  of  the  eye-ball. — 1.  The  ciliary 
nerves  derived  from  the  lenticular  ganglion  and  the 


56  SURGICAL  APPLIED  ANATOMY.     [Chap.  iv. 

nasal  nerve  pierce  the  sclerotic  close  to  the  optic  nerve, 
and  pass  forwards  between  the  sclerotic  and  the 
choroid,  supplying  those  parts.  They  enter  the  ciliary 
muscle,  form  a  plexus  about  the  periphery  of  the  iris, 
and  then  send  fibres  into  the  iris,  which  form  a  fine 
plexus  as  far  as  the  pupil.  They  send  branches  through 
the  fore  part  of  the  sclerotic  to  the  cornea.  Thus  the 
eye-ball  obtains  through  these  nerves  its  sensory  fibres 
from  the  nasal  branch  of  the  first  division  of  the  fifth, 
its  motor  fibres  for  the  ciliary  muscle  and  sphincter 
iridis  from  the  third  nerve,  and  many  sympathetic 
fibres,  among  which  are  those  that  supply  the  dilator 
muscle  of  the  iris.  2.  The  conjunctiva  is  supplied  by 
four  nerves :  above,  the  supratrochlear ;  on  the  inner 
side,  the  infratrochlear ;  on  the  outer  side,  the  lachry- 
mal (all  branches  of  the  first  division  of  the  fifth) ;  and 
below  by  the  palpebral  branches  of  the  second  division 
of  the  fifth.  As  the  ciliary  nerves  pass  forwards 
between  the  choroid  and  the  sclerotic,  it  will  be  seen 
that  they  are  readily  exposed  to  injurious  pressure 
against  the  unyielding  sclerotic  in  cases  of  increased 
intraocular  tension. 

The  sensation  of  the  globe  itself  is  derived 
solely  from  the  first  division  of  the  fifth.  In  inflam- 
matory affections  of  the  globe,  as  in  .corneitis  or  iritis, 
besides  the  pain  actually  felt  in  the  eye,  there  is 
pain  referred  along  other  branches  of  the  first  division 
of  the  fifth.  There  is  pain  over  the  forehead  along  the 
supratrochlear,  supraorbital,  and  lachrymal  branches 
(circumorbital  pain),  and  pain  down  the  side  of  the 
nose  following  the  nasal  nerve.  Or  the  pain  may  spread 
to  the  second  division  of  the  fifth,  and  discomfort  be 
felt  in  the  temporal  region  (orbital  branch  of  second 
division),  or  be  referred  to  the  upper  jaw  and  iipper 
teeth.  These  affections  ai-e  associated  also  with  much 
lachrymation,  the  lachrymal  gland  being  also  supplied 
through  the  first  division  of  the  fifth.  Photophobia, 


chap,  iv.]  THE  ORBIT  AND  EYE.  57 

or  intolerance  of  light,  is  common  in  inflammatory 
affections  of  the  eye.  In  this  condition  there  is  spasm 
of  the  orbicular  muscle,  keeping  the  eye  closed,  or 
closing  it  on  the  least  exposure  to  irritation.  Here 
the  nerve  most  active  is  the  branch  of  the  facial  to 
the  orbicularis,  and  the  reflex  irritation  reaches  that 
nerve  either  through  the  branches  of  the  fifth  in  the 
cornea  and  conjunctiva,  or  through  the  disturbed 
optic  nerve.  Photophobia  is  most  marked  in  super- 
ficial affections  of  the  cornea,  and  is  often  much 
benefited  by  a  seton  in  the  temporal  region.  This 
acts  apparently  by  counter  -  irritation  of  another 
division  (the  second)  of  the  fifth  nerve  supplied  to 
the  region  of  the  temple.  The  relations  between 
the  nasal  nerve  and  the  orbital  contents  receive 
many  illustrations  in  practice.  Thus,  if  the  front 
of  the  nose  be  struck,  or  the  skin  over  its  lower 
part  be  irritated,  as  by  squeezing  a  painful  boil, 
profuse  lachrymation  will  frequently  be  produced. 
Snuff,  too,  by  stimulating  the  nasal  branch  of  the 
ophthalmic  nerve,  often  makes  the  eyes  of  the  un- 
initiated to  water ;  and  it  is  well  known  that  there  are 
many  disturbances  about  the  nose,  and  the  anterior 
part  of  the  nasal  fossae,  that  can  "  make  the  eyes 
water."  Herpes  zoster  often  provides  a  remarkable 
illustration  of  the  intimate  relation  between  the  nasal 
nerve  and  the  eye.  In  this  affection,  when  the  regions 
of  the  supraorbital  and  supratrochlear  branches  of  the 
first  division  are  alone  implicated,  the  eye  is  usually 
unaffected  ;  but  when  the  eruption  extends  over  the 
part  supplied  by  the  nasal  nerve,  i.e.  runs  down  the 
side  of  the  nose,  then  there  is  very  commonly  some 
inflammation  of  the  eye-ball.  In  frontal  neuralgia 
watering  of  the  eye  (irritation  of  the  lachrymal  branch) 
is  very  frequently  met  with. 

The    dangerous    area    of  the    eye. — Pene- 
trating wounds  of  the  cornea  alone,  or  of  the  sclerotic 


58  SURGICAL  APPLIED  ANATOMY.      [Chap. iv. 

alone,  behind  the  ciliary  region,  are  by  no  means 
serious ;  but  wounds  involving  the  ciliary  body,  or  its 
immediate  vicinity,  are  apt  to  assume  the  gravest 
characters.  Inflammation  in  the  ciliary  region  is 
peculiarly  obnoxious,  on  account  of  the  important 
vascular  and  nerve  anastomoses  that  take  place  in  the 
part.  Indeed,  as  regards  blood  and  nerve  supply,  there 
is  no  more  important  district  in  the  eye-ball.  From 
the  ciliary  body  also  inflammations  can  spread,  more 
or  less,  directly  to  the  cornea,  iris,  choroid,  vitreous, 
and  retina.  Plastic,  or  purulent  inflammation  of  the 
ciliaiy  body,  after  injury,  is  the  usual  starting  point 
of  sympathetic  ophthalmia.  In  this  terrible  affection 
destructive  inflammation  is  set  up  in  the  sound  eye, 
which  is,  however,  not  usually  involved  until  two  or 
three  months  after  the  other  eye  has  been  injured. 
"  Although  at  present  the  exact  nature  of  the  process 
which  causes  sympathetic  inflammation  is  unknown, 
and  though  its  path  has  not  been  fully  traced  out,  it  is 
certain  (1)  that  the  change  starts  from  the  region 
most  richly  supplied  by  branches  of  the  ciliary  nerves, 
viz.  the  ciliary  body  and  iris  ;  (2)  that  its  first  effects 
are  generally  seen  in  the  same  part  of  the  sympathising 
eye ;  (3)  that  the  exciting  eye  has  nearly  always  been 
wounded,  and  in  its  anterior  part ;  and  that  decided 
plastic  inflammation  of  its  uveal  tract  is  always 
present ;  (4)  that  inflammatory  changes  have  in  some 
cases  been  found  in  the  ciliary  nerves  and  optic  nerve 
of  the  exciting  eye.  The  morbid  influence  has  of  late 
years  been  generally  believed  to  pass  along  the  ciliary 
nerves,  but  the  earlier  hypothesis  of  transmission 
along  the  optic  nerve  has  recently  been  revived,  and 
further,  the  blood-vessels,  lymphatics,  and  even  the 
blood  itself  are,  at  the  present  time,  claimed  by 
different  authors  as  probable  channels  "  (Nettleship). 

The  lens  measures  ^  of  an  inch  from  side  to  side, 
and  \  of  an  inch  from  before  backwards.      It,  together 


Chap,  iv.]  THE  ORBIT  AND  EYE.  59 

with  its  capsule,  is  in  all  parts  perfectly  transparent 
and  perfectly  non-vascular.  The  lens  may  easily  be 
loosened  or  displaced  by  partial  rupture  of  its 
suspensory  ligament,  and  may  find  its  way  into  the 
anterior  chamber,  or,  more  commonly,  back  into  the 
vitreous.  The  lens,  if  disturbed,  may  swell,  and  by 
the  pressure  thus  exercised  cause  great  damage  to  the 
important  structures  adjacent  to  it.  The  capsule  is 
very  brittle  and  elastic,  and  when  torn  its  edges  curl 
outwards.  It  has  to  be  lacerated  in  all  cataract  opera- 
tions, and  may  be  ruptured  by  many  forms  of  violence 
applied  to  the  eye-ball.  When  the  capsule  is  wounded 
the  aqueous  humoiir  enters,  and  is  imbibed  by  the 
lens  fibres,  which  in  consequence  swell  up,  and  become 
opaque,  thus  producing  a  traumatic  cataract.  In  the 
various  forms  of  cataract  the  whole  lens,  or,  more 
commonly,  some  portion  of  it,  becomes  the  seat  of 
opacity.  This  often  commences  in  the  nucleus,  and 
for  a  long  while  remains  limited  to  that  part ;  or  it 
may  first  involve  the  cortex,  and  in  such  a  case  the 
opacity  takes  the  form  of  a  series  of  streaks  that  point 
towards  the  axis  of  the  lens,  and  are  dependent  upon 
the  arrangement  of  the  lens  fibres.  "  In  so-called 
'  concussion  cataract,'  where  after  a  blow  on  the  eye  a 
part  of  the  lens  becomes  opaque,  it  appears  probable 
that  the  capsule  has  been  very  sHghtly  torn  opposite 
to  the  opacity  "  (Lawford). 

Of  the  retina  it  is  only  necessary  to  observe  that 
its  connection  with  the  choroid  is  so  slight  that  it 
may  easily  be  detached  from  that  membrane  by 
hfemorrhagic,  or  other  effusions,  and  may  indeed  be  so 
detached  by  a  simple  blow  upon  the  globe.  Even 
when  extensively  detached  it  remains,  however,  as 
a  rule,  attached  at  both  the  optic  disc  and  the  ora 
serrata.  The  optic  nerve  as  it  passes  from  the  brain 
receives  its  perineural  sheath  from  the  pia  mater,  and, 
in  addition,  two  other  sheaths ;  an  outer  from  the 


60  SURGICAL  APPLIED  ANATOMY.     [Chap.  iv. 

dura  mater,  and  an  inner  from  the  arachnoid.  These 
sheaths  remain  distinct  and  separate,  and  the  two 
spaces  enclosed  may  be  injected,  the  outer  from  the 
subdural,  the  inner  from  the  subarachnoid  space.  Thus 
inflammatory  affections  of  the  cerebral  meninges  can 
readily  extend  along  the  optic  nerve  to  the  optic  disc 
through  these  spaces  in  the  nerve  sheath,  while  in 
cases  of  intracranial  disease  other  than  meningeal,  the 
mischief  may  extend  from  the  brain  to  the  disc  along 
the  interstitial  connective  tissue  in  the  nerve.  These 
connections  may  serve  in  part  to  explain  the  frequent 
association  of  optic  neuritis  with  intracranial  disease. 
Optic  neuritis  nearly  always  implies  that  the  optic 
disc  or  papilla  is  inflamed,  but  in  exceptional  cases  the 
changes  are  limited  to  that  part  of  the  nerve  behind 
the  globe  (refcro-bulbar  neuritis).  The  entire  length  of 
the  optic  nerve  within  the  orbit  is  28  mm.  to  29  mm. 
The  aqueous  and  vitreous  humour*. — 
The  aqueous  fills  the  space  between  the  capsule  and 
suspensory  ligament  of  the  lens  and  the  cornea.  The 
iris  divides  this  space  into  two  parts,  the  anterior 
and  posterior  chambers.  Since,  however,  the  iris  is 
largely  in  actual  contact  with  the  lens,  it  happens 
that  the  posterior  chamber  is  represented  by  a  little 
angular  interval  between  the  iris,  the  ciliary  processes, 
and  the  zonula  of  the  lens  (Fig.  10).  The  depth  of 
the  anterior  chamber  is  3*6  mm.  The  cornea  at  its 
circumference  breaks  up  into  bundles  of  fibres,  which 
are  partly  continued  into  the  front  of  the  iris,  and 
which  constitute  the  ligamentum  pectinatum  iridis. 
Between  the  processes  of  this  ligament  there  are 
intervals  which  lead  into  certain  cavernous  spaces 
called  the  spaces  of  Fontana.  These  spaces  in  their 
turn  communicate  with  a  large  circular  canal  situate 
in  the  sclerotic  close  to  its  junction  with  the  cornea, 
and  known  as  the  canal  of  Schlemm.  This  space  ig 
in  communication  with  the  veins  of  the  anterior  part 


Cliap.  IV.] 


THE  ORBIT  AND  EYE. 


61 


of  the  sclerotic,*  and  thus  through  this  somewhat 
complicated  channel  the  aqueous  chamber  is  brought 
into  relation  with  the  venous  circulation.  This  re- 
lation probably  explains  the  ready  absorptive  powers 

of  the  aqueous. 
Thus,  if  pus 
finds  its  way 
into  the  ante- 
rior chamber 
(hypopyon)  it 
is  usually  read- 
ily absorbed. 
The  same  ap- 
plies to  mode- 
rate extravasa- 
tions of  blood 
in  the  chamber, 
and  the  speedy 
removal  of  such 
effusions  con- 
trasts with  the 
difficulty  that 
is  experienced 
in  the  absorp- 

Fig.  10.— Section  of  Globe,  showing  Iris,   Lens,  tioil     of     blood 
Ciliary  Region,  etc.    (After  Allen  Thomson.)         from  the  vitl'6- 


a,  Cornea:  b,  sclerotic;  c,  lens;  d,  iris;  c,  ciliary  pro- 
cess;/,  conjunctiva;  <i,  canal  of  Sclilemm  ;  A,  canal 


_„„ 
UUo 


, 

of  Fclit;  f,  anterior  margin  of  vitreous  humour;.?,     rn^_     j.  .,£,„+  „-,„,,  4- 
choroid  covered  by  retina  ;  k,  aqueous  chamber. 

of  soft  cataracts 

by  the  "  needle  operation  "  depends  for  its  success  upon 
the  absorptive  powers  of  the  aqueous.  In  this  pro- 
cedure, the  lens  capsule  having  been  torn  through,  and 
the  cataract  broken  up  with  needles,  the  removal  of 

*  The  precise  manner  in  which  these  spaces  communicate  with 
the  neighbouring  veins  lias  not  been  demonstrated  histplogically. 
The  statement  is  founded  mainly  upon  the  experiments  of 
Schwalbe. 


62  SURGICAL  APPLIED  ANATOMY.     [Chap,  iv 

the  opaque  debris  is  left  to  the  aqueous,  and  it  is  not 
long  before  its  efficacy  in  that  direction  is  seen. 

The  vitreous  takes  little  active  share  in  ocular 
maladies.  It  may  be  secondarily  affected  in  innamina- 
tion  of  adjacent  parts,  may  be  the  seat  of  haemorrhages, 
and  is  often  occupied  by  opaque  bodies  of  various 
kinds.  Foreign  bodies  have  lodged  in  the  vitreous 
for  considerable  periods  without  causing  any  symp- 
toms. The  muscae  volitantes  that  so  often  trouble  the 
myopic  are  due  to  little  opaque  matters  in  the  vitreous, 
and  very  often  have  exactly  the  appearance  that  the 
corpuscles  of  the  vitreous  present  when  seen  under 
the  microscope. 

The  vitreous  is  readily  separated  from  the  retina 
except  behind,  opposite  the  disc  where  the  artery  to 
the  lens  enters  in  the  foetus. 

This  vessel  is  a  branch  of  the  central  artery  of  the 
retina,  and  may  persist  as  a  fibrous  cord  in  adult  life. 
In  some  rare  cases  it  has  continued  to  transmit  blood, 
and  in  such  instances  its  pulsation  can  be  seen  by  the 
ophthalmoscope. 

Glaucoma  is  a  disease  the  symptoms  of  which 
are  all  dependent  upon  an  increase  in  the  intraocular 
tension  of  the  globe.  The  increased  tension  is  due 
to  an  excess  of  fluid  within  the  eye-ball,  and  this  would 
appear  to  be  due  to  certain  changes,  seldom  absent 
in  the  glaucomatous,  that  interfere  with  the  normal 
escape  of  this  fluid.  Normally  there  is  a  constant 
movement  of  fluid  from  the  vitreous  through  the 
suspensory  ligament  into  the  posterior  chamber,  and 
thence  round  the  pupillary  margin  of  the  iris  to  the 
anterior  chamber.  This  fluid  is  derived  mainly  from 
the  ciliary  body,  and  in.  a  less  degree  from  the  pos- 
terior surface  of  the  iris.  Atrophy  of  the  epithelium 
on  the  ciliary  body  is  said  to  lead  to  diminished  ten- 
sion. From  the  anterior  chamber  the  fluid  can  escape 
into  the  v?ins  through  the  gaps  in  the  ligamentum 


Chap,  iv.]  THE  ORBIT  AND  EYE.  63 

pectiiiatum  already  alluded  to  (Fig.  10).  It  is  re 
inarkable  that  in  nearly  every  case  of  glaucoma  these 
gaps  are  occluded  by  the  complete  obliteration  of  the 
angle  between  the  periphery  of  the  iris  and  the  cornea, 
which  angle  is  normally  occupied  by  the  ligamentum 
pectinatum.  The  importance  of  the  peripheral  part  of 
the  anterior  chamber  in  relation  to  the  outflow  of 
fluid  from  the  eye  is  shown  in  many  ways.  If  this 
part  be  blocked  by  the  iris  in  perforation  of  the  cornea, 
or  by  the  lens  in  some  dislocations  of  that  body,  in- 
creased tension  of  the  globe  is  apt  to  follow.  A  like 
increase  of  tension  is  said  to  attend  the  application  of 
the  actual  cautery  to  the  sclero-corneal  margin  and 
some  cases  of  episcleritis.  Dr.  Brailey  believes  that 
some  outflow  also  takes  place  along  the  optic  nerve. 
It  is  well  known  that  pressure  upon  that  nerve  may 
produce  oedema  of  the  disc.  The  relief  given  to 
glaucoma  by  iridectomy  appears  to  depend  upon  the 
circumstance  that  the  operation  practically  opens  up 
again  these  channels  of  communication  from  the 
aqueous,  since  the  procedure,  to  be  successful,  should 
involve  an  incision  so  far  back  on  the  sclerotic  as  to 
fully  pass  through  the  angle  just  alluded  to.  It  is 
needful  also  that  the  iris  should  be  removed  quite  up 
to  its  attachment,  and  that  the  portion  resected  should 
be  considerabla  The  symptoms  of  glaucoma  are  all 
explained  by  the  effects  of  the  abnormal  tension.  Thus, 
the  ciliary  nerves  are  compressed  against  the  unyield- 
ing sclerotic,  and  give  rise  to  intense  pain,  while  the 
disturbance  in  their  function  shows  itself  in  the  fixed 
and  dilated  pupil  and  in  the  anaesthetic  cornea. 
Perhaps  the  first  parts  to  suffer  from  compression  are 
the  retinal  blood-vessels,  and  the  effect  upon  them  will 
be  most  obvious  at  the  periphery  of  the  retina,  i.e. 
at  the  extreme  limit  of  the  retinal  circulation.  Hence 
follows  that  gradually  narrowing  of  the  visual  field 
which  is  constant  in  glaucoma,  while  the  pressure 


64  SURGICAL  APPLIED  ANATOMY.     [Ci>aP  i\. 

upon  the  optic  nerve  produces  those  flashes  of  light 
and  other  spectra  which  occur  in  the  disease.  The 
weakest  part  of  the  sclerotic  is  at  the  disc  at  the 
lamina  cribrosa.  This  part  imapidly  yields  under  the 
pressure,  and  so  produces  the  "  glaucomatous  cup." 
Pressure  in  the  opposite  direction  pushes  the  lens 
forward,  and  thus  narrows  the  anterior  chamber ; 
while  the  general  interference  with  the  ocular  circula- 
tion is  shown  in  the  distended  vessels  that  appear 
upon  the  globe. 

The  eyelids. — The  skrn  over  the  eyelids  is  ex- 
tremely thin  and  delicate,  and  shows  readily  through 
its  substance  any  extravasation  of  blood  that  may 
form  beneath  it.  Its  laxity,  moreover,  renders  it  very 
well  adapted  for  certain  plastic  operations  that  are 
performed  upon  the  part.  Its  loose  attachments 
cause  it  to  be  1'eadily  influenced  by  traction,  and  the 
shrinking  of  cicatrices  below  the  lower  lid  is  very  apt 
to  draw  that  fold  away  from  the  globe,  and  so  produce 
the  condition  of  eversion  of  the  lid  known  as  ectropion. 
The  contraction  of  the  conjunctiva  after  inflammatory 
conditions,  or  after  it  has  been  subjected  to  destructive 
agencies,  is  prone,  on  the  other  hand,  to  curl  either  lid 
inwards  towards  the  globe,  and  to  thus  produce  entro- 
pion.  The  lids  present  many  transverse  folds  ;  one  of 
these  on  the  upper  lid,  deeper  and  more  marked  than 
the  rest,  divides  the  lid  into  two  parts,  the  part  belo\v 
being  that  that  covers  the  globe,  the  part  above  being 
that  in  relation  with  the  soft  structures  of  the  orbit. 
In  emaciation  the  lid  becomes  much  sunken  in  the 
line  of  this  fold.  Incisions  should  follow  the  direc- 
tion of  these  folds.  The  lids  are  very  freely  supplied 
with  blood,  and  are  often  the  seat  of  nsevi  and  other 
vascular  growths.  Rodent  ulcer  so  frequently  attacks 
this  part  that  it  was  originally  known  as  "  Jacob's 
ulcer  of  the  eyelid." 

The  following  layers  are  found   in   either  lid  in 


Chap.  IV.] 


ORBIT  AND  EYE. 


ordei- :  (1)  The  skin ;  (2)  the  subcutaneous  tissue ; 
(3)  the  orbicularis  palpebrarum  ;  (4)  the  tarsal  carti- 
lage  and  ligament ;  (5)  the  layer  of  Meibomian  glands; 

and  (6)  the  conjunctiva. 
In  the  upper  lid  the  le- 
vator  palpebrse  is  found 
passing  to  the  tarsal 
cartilage.  The  subcu- 
taneous tissue  is  very 
lax,  and  hence  the  lids 
swell  greatly  when 
cedematous,  or  when  in- 
flamed, and  when  the 
seat  of  haemorrhage.  On 
this  account  it  is  inad- 
visable to  apply  leeches 
to  the  lids,  on  account 
of  the  extensive  "black 
eye "  that  may  follow. 
This  tissue  is  peculiar 
in  containing  no  fat. 
At  the  edge  of  the  lids 
are  found  the  eyelashes, 
the  orifices  of  the  Mei- 
bomian glands,  and  of 
some  modified  sweat  and 
sebaceous  glands.  This 
edge,  like  other  points 
of  junction  of  skin  and 
mucous  membrane,  is 
apt  to  be  the  seat  of 


irritative  affections.  Be- 
ing a  free  border  also, 


Fig.    11.— Vertical    Section   through 
Ui>per  Eyelid.    (After  Waldeyer.) 

o,  Skin  ;  6,  orlm-ularig  ;  »',  its  ciliary  part ; 
f,  involuntary  muscle  of  eyelid  ;  d,  con- 
junctiva; e,  tarsal  cartilage;/,  Meibo- 
mian  gland;  g,  modified  sweat  gland  ; 
h,  eyelashes  ;  t,  post  tarsal  glands. 

the  circulation  is  termi- 
nal, and  stagnation  in  the  blood  current  is  not  difficult 
to  produce.     Sycosis,  an  inflammation  involving  the 
hair  follicles  and  some  of  the  glands  at  the  edge  of  the 
F— 4 


66  SURGICAL  APPLIED  ANATOMY,     ichap.  iv. 

lid,  is  among  the  most  common  of  ophthalmic  affec- 
tions. The  common  stye  also  is  a  suppuration  in 
the  connective  tissue  or  in  ono  of  the  glands  at 
the  margin.  On  everting  the  lid  the  Meibomian 
glands  can  be  seen  through  the  conjunctiva  as 
lines  of  yellowish  granules.  The  common  tarsal 
cyst  is  a  retention  cyst  developed  in  one  of  these 
glands. 

Two  arteries  supply  either  lid :  a  palpebral  branch 
of  the  ophthalmic  running  along  the  inner  part  of 
each  lid,  and  a  branch  of  the  lachrymal  along  the 
outer  part  of  each  lid.  Four  nerves  supply  the  upper 
eyelid,  the  supraorbital,  the  supra-  and  infratrochlear, 
and  the  lachrymal.  One  nerve  supplies  the  lower  lid, 
the  infraorbital.  Some  of  the  lymphatics  of  the  eye- 
lids enter  the  fore-auricular  glands,  hence  in  cases  of 
chancre  of  the  lid  the  bubo  has  nearly  always  been 
noticed  in  front  of  the  parotid  gland. 

The  conjunctiva. — The  ocular  part  of  this 
membrane  is  thin,  very  loosely  attached,  and  not  very 
extensively  supplied  with  blood ;  the  palpebral  portion 
is  thicker,  more  closely  adherent,  and  more  vascular. 
At  the  edge  of  the  cornea  the  conjunctiva  becomes 
continuous  with  the  epithelium  covering  that  tunic. 
The  looseness  of  the  ocular  conjunctiva  allows  it  to  be 
freely  moved  about,  and  is  of  great  value  in  some 
operations :  as,  for  example,  in  Teale's  operation  for 
symblepharon,  where  a  bridge  of  conjunctiva,  dis- 
sected up  from  the  globe  above  the  cornea,  is  drawn 
down  over  the  cornea  to  cover  a  raw  surface  in 
contact  with  the  lower  lid.  This  lax  tissue  favours 
the  development  of  O3clema  (chemosis),  which  in 
extreme  cases  may  reach  such  a  degree  that  the  patient 
cannot  close  his  eye.  The  vessels  also,  being  feebly 
supported,  are  prone  to  give  way  under  no  great 
provocation.  Thus,  subconjunclival  haemorrhages  may 
occur  from  severe  vomiting,  or  during  a  paroxysm  of 


chap,  iv.)  THE  ORBIT  AND  EYE.  67 

whooping  cough.  Blood  also  may  find  its  way  beneath 
the  membrane  in  fractures  of  the  base  of  the  skull. 
Haemorrhages  beneath  the  membrane  are  unlike  other 
extravasations  (bruises),  in  that  they  retain  their 
scarlet  colour.  This  is  due  to  the  fact  that  the 
thinness  of  the  conjunctiva  allows  oxygen  to  reach  the 
blood  and  retain  for  it  an  arterial  character.  Severe 
inflammation  of  the  conjunctiva  may  lead  to  con- 
siderable cicatricial  changes,  as  is  the  case  in  other 
mucous  membranes,  and  especially,  perhaps,  in  the 
urethra.  The  contraction  of  the  conjunctiva  after 
destructive  processes  is  apt  to  lead  to  entropion.  If 
both  the  ocular  and  the  corresponding  part  of  the 
palpebral  conjunctiva  have  been  destroyed,  the  two 
raw  surfaces  left  will  readily  adhere ;  the  lid  will 
become  fused  to  the  globe,  and  the  condition  called 
symblepharon  be  produced.  This  condition  concerns 
the  lower  lid,  and  is  generally  brought  about  by  lime 
or  other  caustics  being  accidentally  introduced  be- 
tween the  under  lid  and  the  globe. 

In  one  common  form  of  inflammation  of  this 
membrane  a  number  of  little  "  granulations  "  appear 
upon  the  palpebral  conjunctiva.  These  are  not 
real  granulations,  since  no  true  ulceration  of  the 
part  takes  place,  but  they  appear  to  be  made  up, 
some  of  nodules  of  adenoid  tissue,  others  of  en- 
larged mucous  follicles  and  of  hypertrophied  papillae, 
all  of  which  structures  are  normally  found  in  the 
aiembrane.  The  condition  is  known  as  "  granular 
lids,"  and  is  associated  with  the  formation  of  much 
new  tissue  in  the  deeper  parts  of  the  membrane. 
From  the  absorption  of  this  new  tissue  and  of 
these  granulations  a  contracting  cicatrix  results, 
leading  to  much  puckering  of  the  membrane,  and 
often  to  entropion  and  inversion  of  the  eyelashes. 
In  purulent  ophthalmia  the  cornea  is  in  great  risk  of 
destruction,  owing  to  the  strangulation  of  its  vessels, 


68  SURGICAL  APPLIED  ANATOMY.     [Chap,  iv 

and  to  the  effects  possibly  of  the  discharge  directly 
upon  the  membrane. 

The  lachrymal  apparatus. — The  lachrymal 
gland  is  invested  by  a  special  fascia  which  separates 
it  from  the  general  cavity  of  the  orbit ;  and,  according 
to  Tillaux,  this  little  body  can  be  removed  without 
opening  the  greater  space  of  the  orbit.  The  gland 
may  inflame,  and  become  so  enlarged  as  to  appear  as 
a  tumour,  which  may  displace  the  globe  downwards 
and  inwards,  and  press  forwards  the  oculo-palpebral 
fold  of  conjunctiva.  If  an  abscess  forms,  it  most 
usually  breaks  through  the  skin  of  the  upper  lid. 
Cysts  of  the  gland  (dacryops)  are  due  to  obstruction 
and  distension  of  some  of  its  ducts. 

The  lachrymal  sac  is  situated  at  the  side  of  the 
nose,  near  the  inner  canthus,  and  lies  in  a  groove  on 
the  lachrymal  and  superior  maxillary  bones.  On  its 
outer  side,  and  a  little  anteriorly,  it  receives  the 
lachrymal  canals.  In  front  of  the  sac  is  the  tendo  oculi. 
If  the  two  lids  be  forcibly  drawn  outwards  this  tendon 
can  be  readily  felt  and  seen,  and  is  the  great  guide  to 
the  sac.  It  can  also  be  felt  as  it  is  tightened,  when  the 
lids  are  firmly  closed.  It  crosses  the  sac  at  right  angles, 
and  at  about  the  junction  of  its  upper  third  with  its 
lower  two-thirds.  A  knife  entered  immediately  below 
the  tendon  Avould  about  open  the  middle  of  the  sac,  and 
it  may  be  noted  that  a  lachrymal  abscess,  when  about  to 
discharge,  always  points  below  the  tendon.  Epiphora, 
or  overflow  of  tears,  is  due  in  the  main  to  two  causes : 
(1)  To  an  obstruction  in  any  part  of  the  lachrymal 
passages  from  the  puncta  to  the  opening  of  the  nasal 
duct  in  the  nose ;  (2)  to  any  cause  that  removes  the 
lower  punctum  from  its  contact  with  the  globe,  as 
may  be  the  case  in  ectropion,  in  entropion,  in 
swelling  of  the  lower  lid,  etc.  Facial  palsy  causes 
epiphora,  because,  the  orbicular  muscle  being  relaxed, 
the  punctum  falls  away  from  the  globe,  and,  moreover, 


Chap,  v.)  THE  EAR.  69 

the  passage  of  the  tears  is  no  longer  aided  by  the 
suction  action  effected  by  the  muscle  in  the  process  of 
winking.  The  canaliculi  may  readily  be  slit  up  by 
a  proper  knife,  and  a  probe  can  without  difficulty  be 
passed  down  the  nasal  duct  from  the  lachrymal  sac. 
The  duct  is  a  little  over  half  an  inch  in  length,  and 
the  probe  that  traverses  it  should  pass  downwards, 
and  a  little  backwards  and  outwards. 

As  affections  of  the  lachrymal  sac  are  often  very 
painful,  it  may  be  noted  that  the  nerve  supply  of  the 
sac  is  derived  from  the  infratrochlear  branch  of  the 
nasal  nerve. 


CHAPTER  V. 

THE    EAR. 

THE  pinna  and  external  auditory  meatus* 

— The  pinna  may  be  congenitally  absent,  or  may  be 
supplemented  by  supernumerary  portions  of  the 
auricle,  which  may  be  situated  upon  the  cheek  or 
side  of  the  neck.  In  the  latter  situation  the  so-called 
supernumerary  auricle  consists  in  an  irregular  leaf  of 
fibro-cartilage  developed  from  the  margins  of  one  of 
the  lower  branchial  clefts.  (See  page  168.)  The  tag- 
like  supernumerary  auricles  that  are  fcmnd  on  the 
cheek  just  in  front  of  the  pinna  or  meatus,  are  due 
to  the  irregular  development  or  want  of  fusion  of  one 
or  more  of  the  six  tubercles  from  which  the  pinna 
itself  is  developed.  The  pinna  may  present  a  con- 
genital fistula.  This  may  be  due  to  a  defective 
closure  of  the  first  branchial  cleft.  This  cleft  is 
represented  in  the  normal  ear  by  the  Eustachian  tube, 
the  tympanum,  and  the  external  auditory  meatus,  the 
pinna  being  developed  from  the  integument  behind 


70  SuKGrcAL  APPLIED  ANATOMY.       [Chap. v. 

the  cleft.  In  these  congenital  fistulpe,  when  well 
marked,  the  pinna  is  cleft  just  in  front  of  the  tragus, 
or  through  the  helix,  and  there  is  more  or  less  failure 
in  the  closing  of  the  meatus  and  tympanum,  while  the 
membrana  tympani  will  be  more  or  less  deficient,  or 
entirely  absent.  In  other  cases  the  "  fistula  "  appears 
merely  as  a  narrow  sinus  or  a  depression,  running 
through  and  from  the  helix.  Some  of  the  smaller  and 
more  superficial  fistulas  are  due  not  to  a  defective 
closure  of  the  branchial  cleft,  but  to  want  of  complete 
fusion  between  certain  of  the  tubercles  from  which 
the  pinna  is  primarily  developed.  Accidental  removal 
of  the  pjnna  is  usually  associated  with  but  compara- 
tively little  diminution  in  the  acuteness  of  hearing. 

The  skin  covering  the  auricle  is  thin  and  closely 
adherent.  The  subcutaneous  tissue  is  scanty,  and 
contains  but  very  little  fat.  In  inflammatory  condi- 
tions of  the  surface,  such  as  erysipelas,  the  pinna  may 
become  extremely  swollen  and  very  great  pain  be 
produced  from  the  tenseness  of  the  parts.  The  pinna 
and  cartilaginous  meatus  are  very  firmly  attached  to 
the  skull,  so  that  the  body,  if  not  of  great  weight, 
may  be  lifted  from  the  ground  by  the  ears. 

In  chronic  gout,  little  deposits  of  urate  of  soda 
(called  tophi)  are  often  met  with  in  the  pinna,  and  are 
usually  placed  in  the  subcutaneous  tissue  at  the  edge 
of  the  helix.  M.  Paul  has  pointed  out  that,  when 
ear-rings  are  worn,  the  usual  hole  made  by  the  ring 
may  become  converted  into  a  vei'tical  slit,  or  the  ear- 
ring may  cut  its  way  out,  leaving  a  slit  in  the  lobule. 
This  it  may  do  several  times  if  re-applied,  thus  pro- 
ducing many  slits  in  the  same  lobule.  He  considers 
such  conditions  as  absolutely  diagnostic  of  scrofula.* 

The  external  auditory  meatus  is  about  \\ 
inches  long.  It  is  directed  forwards  and  inwards, 

*  See   "Scrofula  and  its   Gland  Diseases,"  by   the   Author. 
Lond.     1882. 


Chap.  V  1 


THE  EAR. 


having  the  same  direction  as  the  petrous  bone.  The 
external  meatus,  the  promontory,  the  cochlea,  and  the 
internal  meatus  lie  nearly  in  the  same  line.  The 
canal  has  a  vertical  curve  about  its  middle,  with  the 


Fi<*.   12. — Section  through  the  external  Meatus,  Middle  Ear,  and 
Eustachiau  Tube  (Tillanx). 

«,  External  auditory  mentiis  ;  6,  tympanum  ;  e,  EiiBtaeliian  tnho  ;  d,  internal 
auditory  mcatus ;  e,  cochlea ;/,  Mticlea ;  <j,  lucinbrana  tympani;  ft,  -ijl.ihl 
process. 

convexity  upwards.  To  straighten  the  canal  for  the 
introduction  of  specula  and  other  instruments,  the 
pinna  should  be  drawn  upwards  and  a  little  outwards 
and  backwards.  The  osseous  part,  forms  a  little  more 
than  one-half  of  the  txibe,  and  is  narrower  than  the 
cartilaginous  part. 

Jn  the  infant  at  one  year,   a  third  only  of   the 


72  SURGICAL  APPLIED  A. \ATOMY.       tchar. v 

meatus  is  formed  of  bone.  The  rest  is  cartilaginous. 
In  a  child  of  five  or  six  years  of  age  the  bony  and  car- 
tilaginous portions  of  the  meatus  are  about  of  the 
same  length  (Symington).  The  meatus  is  relatively 
as  long  in  a  child  as  it  is  in  an  adult.  The  narrowest 
portion  of  the  meatus  is  about  its  middle.  The  outer 
orifice  is  elliptical,  with  its  greatest  diameter  directed 
from  above  downwards ;  therefore  specula  should  be 
elliptical  in  shape  rather  than  round.  The  inner  end 
of  the  tube,  on  the  other  hand,  is  slightly  wider  in 
the  transverse  direction.  Owing  to  the  obliquity  of 
the  membrana  tympani,  the  floor  of  the  meatus  is 
longer  than  the  roof.  The  cartilaginous  segment  of 
the  tube  presents  many  sebaceous  glands  that  may  be 
the  seat  of  minute  and  very  painful  abscesses.  It 
also  presents  numerous  ceruminous  glands,  which 
secrete  the  cerumen  of  the  ear,  and  which,  when  their 
secretion  is  excessive,  may  produce  the  plugs  of  wax 
that  often  block  the  meatus.  Lacerated  wounds  of 
the  cartilaginous  meatus  are  apt  to  bleed  freely,  ow- 
ing to  the  difficulty  with  which  the  vessels  bound  up 
with  the  cartilage  contract.  In  the  floor  of  this  part 
of  the  meatus  are  certain  fissures,  fissures  of  San- 
torini.  They  are  filled  up  with  fibrous  tissue.  They 
permit  of  easier  movement  of  the  cartilaginous  meatus. 
It  is  through  these  gaps  in  the  cartilage  that  a  parotid 
abscess  may  burst  into  the  meatus.  There  are  neither 
hairs  nor  glands  in  the  lining  of  the  bony  part  of  the 
tube. 

The  skin  of  the  meatus,  when  inflamed,  may  pro- 
duce an  extensive  muco-purulent  discharge,  obitis 
externa.  Polypi  are  apt  to  grow  from  the  soft  parts 
of  the  canal,  and  exo.stoses  from  its  bony  wall. 
Foreign  bodies  are  frequently  lodged  in  the  meatus, 
and  often  involve  great  difficulties  in  their  extraction. 
It  would  appear  that  in  many  cases  more  damage  is 
4one  by  the  surgeon  than  by  the  intruding  substance. 


chnp.v.j  THE  EAR.  73 

Mason  reports  three  cases  where  a  piece  of  slate-pencil, 
a  cherry-stone,  and  a  piece  of  cedar-wood  were  lodged 
in  the  canal  for  respectively  forty  years,  sixty  years, 
and  thirty  years. 

The  upper  wall  of  the  meatus  is  in  relation 
with  the  cranial  cavity,  from  which  it  is  only 
separated  by  a  dense  layer  of  bone.  Thus,  abscess  or 
bone  disease  in  this  part  may  possibly  lead  to  menin- 
gitis. A  case  is  reported  where  an  inflammation  of 
the  cerebral  membrane  followed  upon  the  retention  of 
a  bean  within  the  meatus.  The  anterior  wall  of  the 
canal  is  in  relation  with  the  temporo-maxillary  joint 
and  with  part  of  the  parotid  gland.  This  may  serve 
in  one  way  to  explain  the  pain  often  felt  in  moving 
the  jaw  when  the  meatus  is  inflamed,  although,  at  the 
same  time,  it  must  be  remembered  that  movement  of 
the  lower  maxilla  produces  a  movement  in  the  carti- 
laginous meatus,  and  that  both  the  canal  and  the  joint 
are  supplied  by  the  same  nerve  (the  auriculo-temporal). 
From  its  relation  to  the  condyle  of  the  jaw,  it  follows 
that  this  wall  of  the  meatus  has  been  fractured  by 
that  condyle  in  falls  upon  the  chin.  Tillaux  states 
that  abscess  in  the  parotid  gland  may  spread  into  the 
meatus  through  the  anterior  wall  of  the  passage. 
The  posterior  wall  separates  the  meatus  from  the 
mastoid  cells,  and  through  this  partition  inflammation 
may  extend  from  one  part  to  the  other,  especially  as 
the  cartilage  of  the  tube  is  deficient  at  its  upper  and 
posterior  parts.  Directly  behind  the  posterior  wall 
is  the  lateral  sinus.  The  inferior  wall  of  the  bony 
meatus  is  very  dense  and  substantial,  and  corresponds 
to  the  vaginal  and  styloid  processes. 

Blood  supply. — The  pinna  and  external  meatus 
are  well  supplied  with  blood  by  the  temporal  and 
posterior  auricular  arteries,  the  meatus  receiving  also 
a  branch  from  the  internal  maxillary.  In  spite  of 
this  supply,  the  pinna  is  frequently  the  seat  of 


74  SURGICAL  APPLIED  ANATOMY.       [Chap. v. 

gangrene  from  frost-bite.  This  is  due  to  the  fact  that 
all  the  vessels  are  superficial  and  are  close  beneath  the 
surface,  that  the  part  is  much  exposed  to  cold,  and 
that  the  pinna  lacks  the  protection  of  a  covering  of 
fat.  The  same  conditions  predispose  to  gangrene  of 
the  nose  from  external  cold.  Bloody  tumours 
(hsematomata)  are  often  met  with  on  the  pinna,  and 
are  said  to  be  more  common  in  lunatics.  They 
appear  to  be  frequently  due  to  injury,  and  consist  of 
an  extravasation  between  the  perichondrium  and  the 
cartilage. 

Nerve  supply. — The  outer  siirface  of  the  pinna 
is  supplied  by  the  auriculo-temporal  nerve,  with  the 
exception  of  the  skin  over  the  antitragus,  the  vertical 
part  of  the  antihelix,  the  corresponding  part  of  the 
helix  and  its  fossa,  and  the  lobule,  which  parts  are 
all  supplied  by  the  great  auricular  nerve.  The  inner 
s\irface  is  almost  entirely  supplied  by  the  latter  nerve, 
the  small  occipital  nerve  giving  a  branch  to  the 
upper  extremity,  and  Arnold's  nerve  a  branch  to  the 
back  of  the  concha,  near  the  mastoid  process.  The 
meatus  is  supplied  mainly  by  the  auriculo-temporal, 
with,  in  addition,  a  contribution  from  Arnold's  nerve, 
which  goes  to  the  lower  and  back  part  of  the  canal, 
not  far  from  its  commencement.  Arnold's  nerve,  a 
little  branch  from  the  pneumo-gastric,  has  been 
credited  with  a  good  deal  in  connection  with  the 
nerve  relations  of  the  ear.  After  a  heavy  dinner, 
when  the  rose-water  comes  round,  it  is  common  to  see 
the  more  experienced  of  the  diners  touch  the  lower 
part  of  the  back  of  the  ear  with  the  moistened 
serviette.  This  is  said  to  be  very  refreshing,  and  is 
supposed  to  prove  to  be  an  unconscious  stimulation  of 
Arnold's  nerve,  a  nerve  whose  main  trunk  goes  to 
the  stomach.  Hence,  this  little  branch  has  been 
facetiously  termed  "  the  alderman's  nerve." 

Ear  coughing,  ear  sneezing,  ear  yawning 


chap,  v.]  THE  EAR.  75 

— It  is  not  uncommon  to  have  a  troublesome  dry 
cough  associated  with  some  mischief  in  the  roeatus. 
Sometimes  the  mere  introduction  of  a  speculum  will 
make  the  patient  cough.  A  case  is  reported,  where 
a  troublesome  cough  persisted  for  eighteen  months, 
and  at  once  ceased  on  the  removal  of  a  plug  of  wax 
from  the  par.  In  such  cases,  the  irritation  is  probably 
conveyed  to  the  trunk  of  the  vagus  by  Arnold's 
nerve,  and  is  then  referred  to  the  respiratory  tracts 
which  are  so  extensively  supplied  by  that  trunk.  By 
means  of  this  little  branch  the  ear  is  brought  into 
very  direct  connection  with  the  great  nerve  of  the 
lung.  Dr.  Woakes  has  carefully  investigated  the 
matter  of  ear-sneezing,  d  propos  of  a  case  where 
troublesome  sneezing  was  set  up  by  a  plug  of  wax  in 
the  meatus.  He  considers  that  the  irritation  in  this 
case  also  is  conveyed  to  the  respiratory  organs  by 
Arnold's  nerve.  The  relation  of  this  small  nerve  to 
the  nerve  of  the  stomach  is  illustrated  by  a  case 
cited  by  Arnold,  where  severe  chronic  vomiting  was 
at  once  cui-ed  by  extracting  from  each  ear  of  a  child 
a  bean  that  had  been  introduced  in  play. 

In  the  repeated  yawning  that  is  sometimes  set  up 
by  ear  ailments,  the  irritation  is  no  doubt  conveyed 
from  the  meatus  by  the  auriculo-temporal  nerve. 
This  nerve  is  a  branch  of  the  third  division  of  the 
fifth,  and  it  is  from  this  same  division  that  the 
branches  come  off  that  supply  the  muscles  of  the  jaw. 

The  inferior  dental  nerve,  that  goes  to  the  lower 
teeth,  is  a  branch  of  the  same  division,  as  is  also  the 
gustatory  nerve ;  and  the  somewhat  direct  connection 
of  these  nerves  with  the  ear  may  explain  the  frequent 
association  of  ear-ache  and  tooth-ache,  and  V.he  fact 
that  disease  in  the  anterior  part  of  the  tongue 
(gustatory  nerve)  is  often  attended  by  pain  in  the  ear. 

It  is  a  common  practice  to  introduce  ear-rings, 
with  the  idea  of  relieving  obstinate  affections  of  the 


76  SURGICAL  APPLIED  ANATOMY.       [Chap.  v. 

eye.  How  such  a  treatment  can  act,  if  it  acts  at 
all,  is  hard  to  understand.  It  is  true  that  the  main 
nerve  supply  of  the  eye  and  of  the  conjunctiva  comes 
from  the  fifth  nerve,  but,  unfortunately  for  any  nerve 
theory,  the  lobule  of  the  ear  is  only  supplied  by  the 
great  auricular  nerve.  If  the  ear-ring,  in  such  cases, 
were  introduced  through  the  upper  part  of  the  ear, 
supplied  as  it  is  in  front  by  the  fifth  nerve,  some 
connection  might  be  traced. 

Hilton  reports  a  case  of  obscure  pain  in  the  ear 
which  was  found  to  be  due  to  an  enlarged  gland  in  the 
neck,  that  pressed  upon  the  trunk  of  the  great  auri- 
cular nerve. 

Jttembrana  lyiujmiii. — This  membrane  is  very 
obliquely  placed,  forming  with  the  horizon  an  angle 
of  45°.  At  birth  it  appears  to  be  more  nearly  hori- 
zontal, although  it  is  not  really  so.  In  cretins,  and 
in  some  idiots,  it  is  said  to  retain  this  apparent  in- 
clination. Owing  to  the  sloping  downwards  of  the 
bony  wall  of  the  meatus  at  its  inner  end,  that  wall 
forms  with  the  lower  edge  of  the  mernbrana  a  kind  of 
sinus  in  which  small  foreign  bodies  may  readily  lodge 
(Fig.  12).  The  ring  of  bone  to  which  the  membrane 
is  attached  is  deficient  at  its  upper  and  anterior  part. 
The  gap  so  formed  is  called  the  notch  of  Rivini,  and 
is  occupied  by  loose  connective  tissue,  covered  by  a 
continuation  of  the  lining  of  the  meatus,  and  through 
it  pus  may  escape  from  the  middle  ear  into  the 
auditory  canal  without  perforating  the  membrane. 
When  the  membrane  gives  way  owing  to  a  violent 
concussion  transmitted  through  the  air,  it  often  gives 
way  opposite  the  notch,  its  attachments  here  being 
obviously  less  secure  than  elsewhere.  The  membrane 
possesses  but  little  elasticity,  as  shown  by  the  very 
slight  gaping  of  the  part  after  it  has  been  wounded. 
Tt  is  for  this  reason,  among  others,  that  perforations 
rjiade  in  the  membrane  by  the  surgeon  heal  so  very 


chaP.v.]  THE  EAR.  77 

rapidly.  The  membrane  has  been  ruptured  during 
fits  of  sneezing,  coughing,  vomiting,  etc.  The  same 
lesion  has  followed  a  box  on  the  ear,  and  even  simple 
concussion  such  as  that  produced  by  a  loud  report 

The  umbo,  or  deepest  point  of  the  depression  in 
the  diaphragm,  is  just  below  the  centre  of  the  entire 
membrane,  and  corresponds  to  the  attachment  of  the 
end  of  the  handle  of  the  malleus.  The  rest  of  the 
handle  can  be  seen  through  the  membrane  during  life. 
The  head  of  the  malleus  is  in  no  connection  with  the 
membrane,  being  above  its  highest  limits.  The  seg- 
ment of  the  membrane  above  the  umbo  is  very  freely 
supplied  by  vessels  and  nerves  ;  it  corresponds  to  the 
handle  of  the  malleus,  and  to  the  chain  of  ossicles,  and 
is  opposite  to  the  promontory  and  the  two  fenestrse. 
The  chorda  tympani  nerve  also  runs  across  this  supra- 
umbilical  portion.  The  segment  below  the  umbo,  on 
the  other  hand,  corresponds  to  no  very  important 
parts,  and  is  less  vascular  and  less  sensitive.  Para- 
centesis  of  the  tympanum  through  the  membrana 
tympani  should  therefore  always  be  performed  in  the 
subumbilical  segment.  If  performed  above  the  umbo 
the  knife  may  strike  the  incus  and  loosen  that  bone 
from  its  frail  attachments.  The  malleus  and  stapes 
are  too  firmly  attached  to  be  readily  separated. 

The  membrane  is  supplied  by  the  stylo-mastoid 
artery,  and  the  tympanic  branch  of  the  internal  max- 
illary, and  obtains  its  nerve  supply  from  the  auriculo- 
teinporal. 

The  tympanum.  —  The  width  of  the  tympanic 
cavity,  as  measured  from  its  inner  to  its  outer  wall, 
varies  from  T\th  to  ^th  of  an  inch.  The  narrowest 
part  is  that  between  the  umbilicus  of  the  membrana 
and  the  promontory.  A  fine  rod  thrust  through  the 
centre  of  the  membrana  tympani  would  hit  the  pro- 
montory on  the  inner  wall  of  the  cavity.  Above 
the  promontory  is  the  fenestra  ovalis,  and  below  and 


78  SURGICAL  APPLIED  ANATOMY.       [Chap. v. 

behind  it  the  fenestra  rotunda.  Skirting  the  upper 
and  posterior  margin  of  the  inner  wall  of  the  tympa- 
num is  the  aqueduct  of  Fallopius,  containing  the 
facial  nerve.  The  wall  of  the  aqueduct  is  so  thin  that 
inflammatory  mischief  can  readily  extend  from  the 
middle  ear  to  the  facial  nerve.  The  upper  wall  is 
very  thin,  and  but  little  bone  separates  it  from  the 
cranial  cavity.  The  suture  between  the  squamous 
and  petrous  bones  is  found  in  this  wall,  and  by  means 
of  the  sutural  membrane  that  separates  the  bones  in 
the  young  inflammatory  changes  may  readily  spread 
from  the  tympanum  to  the  meninges.  This  petro- 
squamous  suture  is  generally  obliterated  by  the  end  of 
the  first  year  (Symington).  The  floor  is  very  narrow. 
Its  lowest  part  is  below  the  level  of  both  the  rnern- 
brana  tympani  and  the  orifice  of  the  Eustachian  tube, 
and  hence  pus  may  readily  collect  in  this  locality.  It 
is  separated  by  a  thin  piece  of  bone  from  the  internal 
jugular  vein  behind,  and  from  the  internal  carotid 
artery  in  front.  Fatal  haemorrhage  from  the  latter 
vessel  has  occurred  in  connection  with  destructive 
changes  in  this  part  of  the  ear.  The  posterior  wall 
presents  the  openings  of  the  mastoid  cells. 

The  mastoid  cells  are  often  the  seat  of  sup- 
purative  collections,  due  to  the  spreading  of  inflamma- 
tion from  the  tympanum.  The  implication  of  these 
spaces  forms  one  of  the  most  important  complications 
of  middle  ear  disease.  In  the  infant  the  mastoid  as 
a  distinct  process  has  no  existence,  but  in  the  mastoid 
segment  of  the  petrous  bone  is  a  single  air  cell,  the 
mastoid  anlruni,  which  communicates  by  a  large 
opening  with  the  posterior  part  of  the  upper  portion 
of  the  tympanum  above  the  membrana.  The  roof  of 
this  cell  is  quite  close  to  the  cranial  cavity,  while  its 
outer  wall  is'  very  thin,  about  2  mm.  in  thickness. 
From  the  latter  fact  it  happens  that  in  infants  pus  in 
the  antrum  can  very  readily  reach  the  surface,  or  be 


Chap,  v.)  THE  EAR.  79 

still  more  readily  evacuated  by  operation.  Across  the 
roof  of  the  antrum  runs  the  petro-squatnous  suture. 
About  the  second  year  the  mastoid  process  becomes 
visible.  As  the  bone  increases  its  growth  mainly 
involves  its  external  parts,  so  that  as  years  pass  on  the 
antrum  becomes  more  and  more  deeply  placed.  In  a 
child  aged  nine  this  cell  is  about  1  cm.  from  the 
surface  (Symington).  At  this  period  no  other  air 
cells  exist,  but  at  puberty  an  extensive  series  of  such 
cells  develop. 

In  the  adult  (to  follow  the  account  of  Buck)  these 
mastoid  cells  extend  upwards  to  within  half  an  inch  of 
the  temporo-parietul  suture.  In  this  situation  they  are 
very  close  both  to  the  pericranium  and  to  the  dura 
mater.  Anteriorly  they  extend  forwards  over  the 
external  meatus.  Posteriorly  they  cease  abruptly  at 
the  masto-occipital  suture,  although  in  rare  cases  they 
are  continued  beyond  that  suture  into  the  occipital 
bone.  Very  close  to  the  hinder  cells  is  the  lateral 
sinus. 

About  the  centre  of  the  mastoid  spaces  is  a  single 
cavity,  tJte  antrum.  It  is  about  the  size  of  a  pea.  It 
opens  in  front  into  the  tympanum,  its  floor  occupying 
a  higher  level  than  the  floor  of  that  cavity.  Air  cells 
surround  the  antrum  on  all  sides  (except  towards  its 
roof),  and  open  into  its  cavity.  The  roof  of  the 
untriun  is  only  separated  from  the  cranial  cavity  by  a 
thin  layer  of  bone  about  1  mm.  in  thickness.  The 
distance  of  the  posterior  end  of  the  antrum  from  the 
lateral  sinus  is  from  3  to  6  mm.,  wbile  its  outer  wall  is 
from  i  to  ^ths  of  an  inch  from  the  external  surface  of 
the  mastoid  process.  Emissary  veins  pass  from  the 
mastoid  spaces  to  the  surface  of  the  bone,  and  it  is  no 
doubt  along  these  vessels  that  inflammat'.on  often 
spreads  to  the  soft  parts  behind  the  ear.  Since  the 
same  veins  join  directly  or  indirectly  the  lateral  sinus, 
thrombosis  of  that  sinus  may  readily  follow  mastoid 


8o  SURGICAL  APPLIED  ANATOMY.       [Chap.  V. 

inflammation.  Most  of  the  mastoid  cells  are  air 
spaces,  and  the  majority  open  into  the  antrum.  Some 
few  contain  diploe.  The  cells  vary  greatly  in  size  and 
extent  in  different  individuals.  The  facial  nerve 
passes  close  to  the  mouth  of  the  antrum,  and  may 
readily  be  involved  in  mastoid  disease.  Mastoid  in- 
flammation may  not  only  lead  to  thrombosis  of  the 
lateral  sinus,  but  it  may  readily  extend  (through  the 
antrum  roof)  to  the  membranes  of  the  brain,  and  pro- 
duce meningitis.  It  may  extend  farther  and  cause 
abscess  in  the  neighbouring  part  of  the  brain.  Such 
abscesses  are  usually  in  the  temporo-sphenoidal  lobe  of 
the  cerebrum,  and  next  in  frequency  in  the  cerebellum. 
(See  page  10.)  In  either  case  the  abscess  would  appear 
to  be  due  to  direct  extension  of  inflammation  from 
the  bone. 

In  perforating  the  antrum  to  evacuate  pus  care 
must  be  taken  not  to  wound  the  posterior  auricular 
artery.  The  drill  is  entered  at  a  point  about  ^  of  an  inch 
behind  the  orifice  of  the  meatus  and  a  little  below  the 
level  of  its  upper  wall.  The  instrument  is  thrust  into 
the  bone  in  a  direction  nearly  parallel  with  the 
auditory  canal,  i.e.  inwards  and  a  little  forwards  and 
upwards.  The  antrum  should  be  reached  at  a  depth 
not  exceeding  -|ths  of  an  inch  (Buck). 

In  cases  where  the  outer  surface  of  the  mastoid 
has  been  spontaneously  perforated,  a  tumour  has 
appeared  on  the  skull  that  contained  air,  and  that 
could  be  increased  in  size  by  forcing  air  into  the  ear 
through  the  Eustachian  tube.  Such  tumours  are 
known  as  pneumatoceles,  and  the  process  that  leads 
originally  to  the  perforation  of  the  bone  is  of  obscure 
nature.  In  some  cases  it  seems  to  have  been  simply 
atrophic,  and  in  other  instances  to  have  been  due  to 
"  caries  sicca." 

On  the  anterior  wall  of  the  tympanum  is  the  open- 
ing of  the  Liu  star  Iii  a  ii  tube.  This  tube  is  1]  inches 


chap,  v.i  THE  EAK.  81 

long,  and  by  opening  into  the  pharynx  serves  to  keep 
a  proper  supply  of  air  in  the  tympanum,  and  so 
equalise  the  pressure  upon  the  two  sides  of  the  mem- 
brane. The  floor  of  the  tympanum  is  below  the  level 
of  the  floor  of  the  Eustachian  tube.  The  line  of 
direction  of  the  tube  lies  almost  exactly  midway  be- 
tween the  transverse  and  antero-posterior  axes  of  the 
base  of  the  skull.  In  the  adult  it  inclines  downwards, 
so  as  to  form  an  angle  of  40°  with  the  horizon.  In  the 
child  this  angle  is  only  10"  (Symington).  In  adults 
|ths  of  the  tube  is  cartilaginous  and  £th  bony  (Syming- 
ton). On  the  outer  side  of  the  tube  lie  the  tensor 
palati,  the  third  division  of  the  fifth  nerve  and  the 
middle  meningeal  artery.  On  the  inner  side  are  the 
retro-pharyngeal  tissue  and  (quite  posteriorly)  the 
internal  carotid  artery.  The  pharyngeal  orifice  of  the 
tube  is  usually  shut.  During  swallowing,  however,  it 
is  opened,  by  the  action  mainly  of  the  tensor  palati 
muscle.  If  the  nose  and  mouth  be  closed,  and  the 
cheeks  blown  out,  a  sense  of  pressure  is  produced  in 
both  ears.  The  hearing,  at  the  same  time,  is  dulled, 
and  the  change  is  due  to  the  bulging  out  of  the  mem- 
brana  tympani  by  the  air  thus  forced  into  the  tym- 
panum. This  method  of  inflating  the  middle  ear  is 
known  as  Valsalva's  method. 

In  "  Politzer's  method "  of  passing  air  into  the 
Eustachian  tube,  the  patient's  mouth  is  closed,  while 
into  one  nostril  the  nozzle  of  a  caoutchouc  bag  filled 
with  air  is  introduced,  and  the  nostrils  then  held 
firmly  closed.  The  patient  is  asked  to  swallow  a 
mouthful  of  water,  while  at  the  same  moment  the  bag 
is  forcibly  emptied,  and  the  air,  having  no  other  means 
for  escape,  is  thus  driven  into  the  open  Eustachian 
tube.  The  surgeon  listens  for  the  little  noise  caused 
by  the  entrance  of  the  air  by  means  of  a  tube  that 
passes  between  the  patient's  meatus  and  his  own.  Pro- 
longed closure  of  the  Eustachian  tube  leads  to  deafness, 

G— 4 


82  SURGICAL  APPLIED  AXATOMV.       [Chap. v. 

and  thus  impairment  of  hearing  may  follow  upon  great 
thickening  of  the  mucous  membrane  of  the  tube  due 
to  the  extension  of  inflammatory  mischief  from  the 
pharynx.  In  the  deafness  associated  with  enlarged 
tonsils,  and  post-nasal  growths,  the  hypertrophic 
change  extends  to  the  mucous  lining  of  the  tube,  and 
in  the  cases  of  many  pharyngeal  growths  and  nasal 
polypi,  the  orifice  of  the  tube  is  mechanically  ob- 
structed. The  near  relation  of  the  pharyngeal  end  of 
the  tube  to  the  posterior  nares  serves  to  explain  a  case 
where  suppuration  in  the  mastoid  cells  followed  upon 
plugging  of  the  nares  for  epistaxis.  A  probe  passed 
up  the  Eustachian  tube  from  the  pharynx  would  hit 
the  joint  between  the  incus  and  the  stapes,  and  would 
then  enter  the  mastoid  cells  (Tillaux). 

The  upper  edge  of  the  pharyngeal  orifice  of  the 
tube  is  about  half  an  inch  below  the  basilar  process, 
half  an  inch  in  front  of  the  posterior  wall  of  the 
pharynx,  half  an  inch  behind  the  posterior  end  of 
the  inferior  turbinated  bone,  and  half  an  inch  above 
the  soft  palate  (Tillaux).  In  the  fetus  the  orifice  is 
below  the  hard  palate  :  at  birth  on  the  same  level. 
The  form  of  the  opening  is  that  of  a  triangle.  The 
opening  of  the  tube  is  effected  by  the  tensor  palati, 
levator  palati,  and  salpingo-pharyngeus. 

Just  behind  the  elevation  formed  at  the  orifice  of 
the  Eustachian  tube  there  is  a  depression  in  the  wall 
of  the  pharynx,  known  as  the  fossa  of  Roscnmiiller. 
It  may  be  mistaken  for  the  orifice  of  the  tube,  and 
may  readily  engage  the  point  of  an  Eustachian  cath- 
eter. In  cases  in  which  the  pharyngeal  tonsil  (Luscha's 
tonsil)  is  enlarged,  this  fossa  on  either  side  may  be 
greatly  deepened  and  made  to  form  a  narrow  diverti- 
culum.  (See  page  133.)  To  pass  the  Eustachian  catheter, 
the  instrument  is  carried  along  the  floor  of  the  nares 
with  its  concavity  downwards,  "  until  its  point  can  be 
felt  to  drop  over  the  postei'ior  edge  of  the  hard  palate 


Chap,  v.i  THE  EAR.  83 

into  the  pharynx.  The  instrument  should  now  be 
withdrawn  until  its  point  can  be  felt  to  rise  again  on 
the  posterior  edge  of  the  hard  palate ;  having  arrived 
at  this  point,  the  catheter  should  be  pushed  onwards 
about  one  in-ch,  and  during  its  passage  its  point  should 
be  rotated  outwards  through  a  quarter  of  a  circle."  * 
This  manoeuvre  should  engage  it  on  the  orifice  of  the 
tube. 

Blood  supply. — The  tympanum  is  supplied  by 
the  following  arteries  :  the  tympanic  of  the  internal 
maxillary  and  internal  carotid,  the  petrosal  of  the 
middle  ineningeal,  and  the  stylo-mastoid  of  the  pos- 
terior auricular.  It  is  the  distribution  of  the  main 
trunk  of  the  last-named  vessel  that  gives  some  reason 
for  the  practice  of  applying  blisters  behind  the  ear  in 
disease  located  in  the  deeper  parts.  The  fact  that 
some  of  the  tympanic  veins  end  in  the  superior  petrosal 
and  lateral  sinuses,  gives  another  explanation  of  the 
frequent  occurrence  of  thromboses  of  those  channels 
in  inflammatory  affections  of  the  middle  ear. 

The  cliorda  tynipani  nerve,  from  its  exposed 
position  in  the  tympanum,  is  very  likely  to  be  damaged 
in  suppurative  disease  of  the  middle  ear ;  and  Urban- 
tschitsch  and  Schulte  have  shown  that  such  disease  in 
this  part  may  be  associated  with  anomalies  of  taste. 

The  osseous  labyrinth  is  formed  independently 
of  the  other  bony  parts  of  the  ear.  Portions  of  this 
labyrinth  have  necrosed  and  have  been  expelled  in 
recognisable  fragments.  In  a  case  recorded  by  Dr. 
B.irr  the  whole  of  the  osseous  labyrinth  (the  cochlea, 
vestibule,  and  semicircular  canals)  was  removed  entire 
as  a  necrosed  fragment  from  the  auditory  meatus. 

The  connection  between  deafness  or  tinnitus 
aurium  and  affections  of  the  stomach  has  been  worked 
out  in  the  following  way  (Woakes)  :  The  labyrinth  is 
nourished  only  by  the  vertebral  artery ;  that  vessel  is 
*  Smith  and  Walsham's  "  Operative  Surgery,"  p.  12.  2nd  ed.  1876. 


84  SuRcrcAL  APPLIED  ANATOMY.     [Chap.  vi. 

liberally  supplied  with  nerves  by  the  inferior  cervical 
ganglion.  The  ganglion  communicates  with  the  vagus. 
Troubles  reflected  along  the  vagus  from  the  stomach 
may  reach  the  ganglion,  and  through  it  cause  con- 
gestion of  the  labyrinth,  acting  by  way  of  the  vertebral 
artery. 


CHAPTER  VI. 

THE    NOSE    AND    NASAL    CAVITIES. 

1.  THE  nose. — The  skin  over  the  root,  and  the 
greater  part  of  the  dorsum,  of  the  nooa,  is  thin  and  lax. 
Over  the  alse,  however,  it  is  thick,  very  adherent  to 
the  deeper  parts,  and  plentifully  supplied  with 
sebaceous  and  sweat  glands.  Inflammation  of  the 
integuments  over  the  cartilaginous  portion  of  the 
nose  is  apt  to  be  very  painful,  and  to  be  associated 
with  much  vascular  engorgement.  The  pain  depends 
upon  the  tenseness  of  the  part,  which  prevents  it  from 
swelling  without  producing  much  pressure  upon  the 
nerves,  while  the  engorgement  depends  upon  the  free 
blood  supply  of  the  region,  and  the  fact  that  the  edge 
of  the  nostril  being  a  free  border,  the  circulation  there 
is  terminal,  and  apt  therefore  to  favour  congestion. 

The  great  number  of  sebaceous  glands  about  the 
lower  part  of  the  nose  renders  it  a  favourite  spot  for 
acne.  It  is  here  that  the  form  of  acne  termed  acne 
hypertrophica  is  met  with  ;  a  condition  that  produces 
the  appearance  known  as  "grog  blossoms."  The  nose, 
too,  is  frequently  attacked  by  lupus,  and  it  is  indeed 
over  the  dorsum  of  the  nose  that  lupus  erythematosus 
is  most  commonly  met  with.  llodent  ulcer  also  is  apt 
to  appear  in  this  region,  especially  in  the  fold  between 
the  ala  of  the  nose  and  the  cheek. 


Chap. VI.]          NOSE  AND    NASAL    CAWTIES.  85 

The  integument  of  the  nose  is  very  well  supplied 
with  blood,  and  for  this  reason  the  part  is  well  suited 
for  the  many  plastic  operations  that  are  performed 
upon  it.  Wounds  in  this  region  heal  kindly,  and  even 
the  extensive  wound  made  along  the  line  between  the 
nose  and  the  cheek  in  removal  of  the  upper  jaw  leaves 
very  little  deformity.  In  many  reported  cases  portions 
of  the  nose  have  been  entirely  severed,  and  have 
united  to  the  face  on  being  immediately  re-applied. 
In  spite  of  its  full  blood  supply,  the  nose,  for  reasons 
already  given  when  speaking  of  the  pinna  (page  73), 
is  prone  to  gangrene  from  exposure  to  severe  cold. 
A  specimen  in  the  museum  of  the  Royal  College  of 
Surgeons  illustrates  a  remarkable  form  of  gangrene  of 
the  nose.  The  specimen  is  the  larynx  of  a  man  who 
cut  his  throat,  and  lost  a  great  quantity  of  blood. 
Before  he  died  his  nose  sloughed. 

The  skin  over  the  root  of  the  nose  is  supplied  by 
the  nasal  branch  of  the  first  division  of  the  fifth ;  as 
is  also  the  skin  over  the  alee  and  in  the  region  of  the 
nostril.  The  middle  or  greater  part  of  the  side  of  the 
nose  is  supplied  by  the  second  division  of  the  fifth,  and 
is  the  seat  of  pain  in  neuralgia  of  that  trunk.  The 
fact  that  the  nasal  nerve  is  a  branch  of  the  ophthalmic 
trunk,  and  has  intimate  connections  with  the  eye, 
serves  to  explain  the  lachrymatioii  that  often  follows 
painful  affections  about  the  nostril,  as,  for  example, 
when  the  edge  of  the  nostril  is  pinched  (page  57). 

The  cartilaginous  part  of  the  nose  is  often 
destroyed  by  lupus,  by  syphilitic  ulceration,  and  other 
destructive  affections.  The  parts  so  lost  have  been 
replaced  by  the  various  methods  included  under  the 
head  of  rhinoplasty.  It  is  well  to  bear  in  mind 
the  limits  of  the  cartilaginous  segment  of  the  nose,  and 
to  remember  that  in  introducing  a  dilating  speculum 
the  instrument  should  not  be  passed  beyond  those 
limits.  In  the  subjects  of  inherited  syphilis  the  bridge 


86  SURGICAL  APPLIED  ANATOMY.     [Chap. vi. 

of  the  nose  is  often  found  to  be  greatly  depressed. 
This  depends  upon  no  actual  loss  of  parts,  but  rather 
upon  imperfect  development  from  local  mal-nutrition, 
that  mal-nutrition  following  upon  a  severe  catarrh 
of  the  mucous  membrane.  The  deformity  only 
occurs,  therefore,  in  those  who  have  had  "  snuffles  " 
in  infancy. 

The  nasal  bones  are  often  broken  by  direct 
violence.  The  fracture  is  most  common  through  the 
lower  third  of  the  bones,  where  they  are  thinnest  and 
least  supported.  It  is  rarest  in  the  upper  third, 
where  the  bones  are  thick  and  firmly  held,  and  where, 
indeed,  considerable  force  is  required  to  produce  a 
fracture.  Since  no  muscles  act  upon  the  ossa  nasi, 
any  displacement  that  occurs  is  due  solely  to  the 
direction  of  the  force.  Union  takes  place  after  these 
fractures  with  greater  rapidity  than  perhaps  obtains 
after  fracture  of  any  other  bone  in  the  body.  In  one 
case  noted  by  Hamilton,  "the  fragments  were  quite 
tirmly  united  on  the  seventh  day."  If  the  mucous 
membrane  of  the  nose  be  torn,  these  fractures  are  apt 
to  be  associated  with  emphysema  of  the  subcutaneous 
tissue,  which  is  greatly  increased  on  blowing  the  nose. 
The  air  in  such  cases  is  derived,  of  course,  from  the 
nasal  fossae.  In  fractures  of  the  upper  third  of  the  ossa 
nasi  the  cribriform  plate  may  be  broken,  but  it  is  ques- 
tionable whether  this  complication  can  occur  when  the 
fracture  is  limited  to  the  lower  third  of  the  bones.  The 
root  of  the  nose  is  a  favourite  place  for  nieningoceles 
and  encephaloceles,  the  protrusion  escaping  through 
the  suture  between  the  nasal  and  frontal  bones.  Such 
protrusions,  when  occurring  in  this  place,  are  often 
covered  by  a  thin  and  vascular  integument,  and  have 
been  mistaken  for  nsevoid  growths. 

2.  The  nasal  cavities. — The  anterior  nares 
have  somewhat  the  shape  of  the  heart  on  a  playing 
card,  and  the  aperture  as  a  whole  measures  about 


Chap.  VI.]          NOSE  AND   NASAL    CAVITIKS.  87 

1^  inches  vertically,  and  a  little  less  than  \\  inches 
transversely,  at  its  widest  part.  The  plane  of  the 
nostril  is  a  little  below  that  of  the  floor  of  the  nares. 
To  examine  the  nasal  cavities,  therefore,  the  head 
should  be  thrown  back,  and  the  nose  drawn  upwards. 
The  anterior  nares  can  be  well  explored  by  the  finger 
introduced  into  the  nostril,  and  the  nasal  apertures  are 
just  so  wide  on  each  side  of  the  septum  as  to  allow  the 
finger  to  be  passed  far  enough  back  to  reach  another 
finger  introduced  into  the  posterior  nares  through  the 
mouth.  An  effectual  way  of  removing  soft  polypi  in 
the  adult  is  by  tearing  them  away  by  the  two  fingers 
so  introduced.  The  operation  is  a  little  rough.  By 
the  most  gentle  introduction  of  the  linger  into  the 
nostril  it  is  often  possible  to  feel  the  end  of  the 
inferior  turbinated  bone.  The  anterior  nares,  and 
front  of  the  nasal  cavities,  can  be  well  explored  by 
Rouge's  operation.  In  this  procedure  the  upper  lip 
is  everted,  and  a  transverse  cut  made  through  the 
mucous  membrane  into  the  soft  parts  that  connect  the 
upper  lip  with  the  upper  jaw.  The  incision  extends 
between  the  second  bicuspid  teeth  of  either  side. 
The  soft  parts  connecting  the  upper  lip  and  nose  to 
the  bone  are  divided  without  damaging  the  skin,  and 
the  flap  is  dissected  up  until  the  nares  are  sufficiently 
exposed. 

The  posterior  nares. — If  a  little  mirror, 
somewhat  similar  to  that  used  in  laryngoscopy,  be 
cautiously  introduced  behind  the  soft  palate  through 
the  mouth,  and  illumined  from  the  mouth,  the  following 
parts  may,  under  favourable  circumstances,  be  seen : 
the  posterior  nares,  the  septum,  the  middle  turbinated 
bone,  part  of  the  superior  and  inferior  turbinated 
bones,  and  part  of  the  inferior  meatus.  The  middle 
meatus  is  well  seen,  and  also  the  Eustachian  tube, 
and  the  mucous  membrane  of  the  upper  part  of  the 
pharjux. 


83  SURGICAL  APPLIED  ANATOMY.      [Chap. vi. 

This  mode  of  examination  is  very  difficult  to  carry 
out,  and  is  known  as  posterior  rhinoscopy.  The  parts 
just  named  can  all  be  felt  \>y  the  finger  introduced 
behind  the  soft  palate  through  the  mouth.  The 
posterior  nares  are  often  plugged  to  arrest  severe 
bleeding  from  the  nose,  and  in  order  to  cut  a  proper 
sized  plug  it  is  desirable  to  bear  in  mind  the  dimen- 
sions of  the  apertures.  Each  aperture  is  of  regular 
shape,  and  measures  about  half  an  inch  transversely 
by  one  and  a  quarter  inches  in  the  vertical  direction 
in  a  well-developed  adult  skull. 

As  regards  the  nasal  cavities  generally,  it  is 
well  to  note  that  the  floor  is  wider  at  the  centre 
than  at  either  end,  that  the  vertical  diameter  is 
greater  than  the  transverse,  and  is  greatest  also  about 
the  centre  of  the  fossae.  Forceps  introduced  into  the 
nose,  therefore,  are  most  conveniently  opened  if 
opened  vertically.  The  width  of  the  fossae  increases 
somewhat  from  above  downwards,  thus  the  superior 
turbinated  bone  is  only  2  mm.  from  the  septum, 
while  a  space  of  from  4  to  5  mm.  intervenes  between 
the  inferior  turbinated  bone  and  the  septum.  The 
nasal  cavity  is  so  very  narrow  above  the  middle 
turbinated  bone  that  that  bone  really  forms  the 
surgical  roof  of  the  nasal  fossae. 

From  a  reference  to  the  relations  of  the  nasal 
fossae,  it  will  be  understood  that  inflammation  of  the 
lining  membrane  (coryza)  may  extend  to  the  pharynx 
via  the  posterior  nares ;  may  extend  up  the  Eusta- 
chian  tube  and  cause  some  deafness ;  may  reach  the 
lachrymal  sac  and  conjunctiva  through  the  nasal 
duct ;  and  may  extend  to  the  frontal  sinuses  and  the 
antrum,  producing  frontal  headache  and  cheek-ache. 
These  relationships  are  often  demonstrated  in  a  severe 
"  cold  in  the  head."  From  the  nearness  of  the  nasal 
fossa?  to  the  cranial  cavity  it  happens  that  meningitis 
has  followed  upon  purulent  inflammations  of  the  nose. 


Chuii.  VI.]          ArOS£   AND    NASAL    CAVITIES.  89 

Foreign  bodies  of  various  kind  are  often  lodged  in 
the  nose,  and  may  remain  there  for  some  years.  Thus 
Tillaux  reports  the  case  of  an  old  woman,  aged  64, 
from  whose  nose  he  removed  a  cherry  stone  that  had 
been  there  for  twenty  years. 

In  washing  out  the  nasal  cavities  with  the  "  11:1  sal 
douctic"  the  fluid  is  introduced  by  means  of  a 
syphon.  The  nozzle  of  the  syphon  tube  is  introduced 
into  one  nostril,  the  mouth  is  kept  open,  and  the 
fluid  runs  through  £that  nostril,  passes  over  the  soft 
palate,  and  escapes  from  the  other  nostril.  The  latter 
cavity  is  therefore  washed  out  from  behind  forwards. 
The  course  of  the  fluid  depends  upon  the  fact,  that 
when  the  mouth  is  kept  open  there  is  such  a  dis- 
position to  breathe  through  it  alone,  that  the  soft 
palate  is  drawn  up  and  the  nares  cut  off  from  the 
pharynx. 

The  roof  of  each  nasal  fossa  is  very  narrow,  being 
only  about  ^  of  an  inch  in  width.  It  is  mainly  formed 
by  the  thin  cribriform  plate,  but  its  width  is  such  that 
the  danger  of  the  roof  being  penetrated  by  so  large 
a  substance  as  a  pair  of  polyp  forceps  has  been  greatly 
exaggerated.  The  cranial  cavity  has,  however,  been 
opened  up  through  the  roof  of  the  nose  by  penetrating 
bodies  introduced  both  by  accident  and  with  homicidal 
intent.  Meningitis  has  followed  inflammation  of  the 
nasal  fossae,  the  inflammation  extending  through  the 
cribriform  plate.  Fracture  of  this  part  also  has  been 
associated  with  very  copious  escape  of  cerebro-spinal 
fluid  through  the  nostrils.  A  meningocele  may  pro- 
trude through  the  nasal  roof.  In  a  case  reported  by 
Lichtenberg  the  mass  hung  from  the  mouth,  having 
passed  through  a  congenital  fissure  in  the  palate.  It 
was  mistaken  for  a  polyp,  was  ligatured,  and  death 
resulted  from  intracranial  inflammation. 

The  septum  is  seldom  quite  straight  in  adults ; 
the  deviation  being  more  often  towards  the  left.  It  is, 


go  SURGICAL  APPLIED  ANATOMY.      [Chap. vi. 

however,  straight  in  children,  and  remains  so  up  to 
the  seventh  year.  In  adults  the  septum  deviates  in 
seventy-six  per  cent,  of  all  persons.  The  deviation 
may  follow  an  injury.  It  has  been  pointed  out  that 
a  deviation  of  the  septum  may  seriously  interfere  with 
the  singing  voice.  The  nose  also  is  seldom  quite 
straight,  and  French  authors  ascribe  this  to  some  de- 
viation of  the  septum,  often  dependent  upon  the  prac- 
tice of  always  blowing  the  nose  with  the  same  hand. 
If  the  deviation  of  the  septum  bo  considerable,  it  may 
more  or  less  block  one  nostril,  and,  until  the  opposite 
nostril  is  examined,  be  mistaken  for  a  septal  tumour 
encroaching  upon  the  cavity.  The  flattened  nose  in 
acquired  syphilis  is  usually  due  to  destruction  of  the 
septum,  and  more  or  less  implication  of  the  adjacent 
bones.  Workmen  exposed  to  the  vapour  of  bichromate 
of  potash  are  liable  to  a  peculiar  perforation  of  the 
septum  known  as  "  bichromate  disease." 

Outer  wall. — The  inferior  turbinated  bone  may 
interfere  with  the  introduction  of  a  Eustachian  catheter 
if  the  curve  of  the  instrument  be  too  great.  The 
anterior  end  of  the  bone  is  about  f  of  an  inch  behind 
the  orifice  of  the  nostril.  The  opening  of  the  nasal 
duct  is  about  one  inch  behind  the  orifice  of  the  nostril, 
and  about  |-  of  an  inch  above  the  nasal  floor.  This 
opening  is  usually  round  and  wide.  It  may,  however, 
be  reduced  to  a  slit-like  orifice,  or  even  to  a  minute 
sinus.  The  height  of  the  inferior  meatus  is  about  f  of 
an  inch.  The  superior  meatus  is  a  very  short  and 
narrow  fissure,  and  into  its  upper  and  fore  part  open 
the  posterior  ethinoidal  cells.  The  middle  meatus  opens 
widely  in  front  upon  a  part  of  the  outer  wall  called 
the  atrium,  and  unless  care  be  taken  to  keep  the 
point  of  any  instrument  well  towards  the  floor  of  the 
fossa,  it  is  easier  to  pass  the  instrument  into  the 
middle  than  into  the  inferior  meatus.  Upon  the  wall 
of  the  middle  meatus  is  a  deep  gutter  which  runs 


Chap.  VI J          NOSE   AND   NASAL    CAVITIES.  9! 

from  above  downwards  and  backwards.  Into  this 
groove  (the  infundibulum)  open  the  frontal  sinus,  the 
anterior  ethmoid  cells,  and  the  antrum.  The  aperture 
of  the  frontal  sinus  appears  as  a  small  round  hole  at 
the  upper  and  anterior  end  of  the  groove.  The 
ethmoid  cells  open  a  little  way  lower  down  on  the 
groove,  while  the  antrum  has  its  orifice  at  the  hinder 
part  of  the  infundibulum.  This  orifice  is  slit-like,  is 
about  the  centre  of  the  middle  meatus,  and  is  nearly 
one  inch  above  the  floor  of  the  nasal  fossae.  The 
orifice  is  nearer  to  the  roof  than  the  floor  of  the 
antrum,  and  thus  no  facility  is  offered  for  the  escape 
of  accumulated  fluids. 

The  middle  turbinated  bone  is  high  up.  Its  highest 
point  (its  anterior  extremity)  is  nearly  on  a  level  with 
the  tendo  oculi. 

Rhinolithes  (stone-like  masses  of  calcareous  matter, 
formed,  as  a  rule,  around  foreign  substances)  are  most 
often  found  in  the  inferior  meatus. 

The  width  of  the  nasal  floor  is  about  half  an  inch, 
or  a  little  over.  Its  smooth  surface  greatly  favours 
the  passage  of  instruments.  It  presents  a  gentle  slope 
from  before  backwards.  At  its  anterior  part  is  a 
depression  of  mucous  membrane  over  the  incisor 
foramen.  This  foramen  is  a  vestige  of  the  great  com- 
munication that  once  existed  between  the  cavities  of 
the  nose  and  mouth. 

The  mucous  membrane  lining  the  nasal  cavi- 
ties varies  in  parts.  It  is  very  thick  and  vascular 
over  the  turbinate  bones  and  over  the  lower  two- 
thirds  of  the  septum,  while  over  the  nasal  floor,  and  in 
the  intervals  between  the  turbinate  bones,  it  is  very 
much  thinner.  The  mucous  membrane  lining  the 
various  sinuses  and  the  antrum  is  conspicuously  thin 
and  pale.  The  membrane  is  provided  with  many 
glands,  which  are  most  conspicuous  over  the  lower  and 
hinder  parts  of  the  outer  wall  and  over  the  posterior 


92  SURGICAL  APPLIED  ANATOMY.      [Chap.  vi. 

and  inferior  parts  of  the  septum.  These  glands 
may  be  the  subject  of  considerable  hypertrophy.  They 
are  capable  of  providing  also  a  very  copious  watery 
secretion,  which  has,  in  some  cases  of  chronic  coryza 
following  injury,  been  so  free  as  to  be  mistaken  for  an 
escape  of  cerebro-spinal  fluid.  There  is  also  much 
adenoid,  or  lymphoid,  tissue  in  the  nasal  mucous  mem- 
brane, which  is  the  primary  seat  of  the  chief  scrofulous 
affections  that  invade  this  part.  So  thick  and  lax  is 
the  normal  mucous  membrane  over  the  lower  borders 
and  posterior  extremities  of  the  middle  and  inferior 
turbinated  bones  that  it  forms  in  these  situations  a 
kind  of  soft  cushion.  This  condition  is  mainly  due  to 
the  presence  of  a  rich  submucous  venous  plexus,  the 
vessels  of  which  run,  for  the  most  part,  in  an  antero- 
posterior  direction.  Over  the  lower  turbinate  bone  the 
veins  form  a  kind  of  cavernous  tissue,  "  the  erectile 
body."  When  turgid  with  blood,  it  swells  so  as  to 
obliterate  the  interval  between  the  bone  and  the 
septum.  When  the  seat  of  chronic  inflammation,  the 
mucous  membrane  over  the  inferior  bone  may  appear 
as  a  polypoid  swelling.  The  great  vascularity  of  the 
mucous  membrane  is  probably  for  the  purpose  of 
raising  the  temperature  of  the  inspired  air.  From  the 
construction  of  the  fossse  the  inspired  air  is  encouraged 
to  pass  a  long  the  middle  nieatus,  the  expired  air  along 
the  lower  nieatus.  From  the  comparatively  lax  at- 
tachment of  the  mucous  membrane  of  the  septum  to 
the  parts  beneath,  it  happens  that  hsematomata  are 
often  met  with  beneath  the  septal  mucous  membrane 
after  a  blow  on  the  nose. 

Polypi  are  often  met  with  in  the  nose.  They 
are  of  two  kinds,  the  mucous  or  myxomatous  polyp 
that  springs  usually  from  the  mucous  membrane 
over  the  middle  or  inferior  turbinate  bones,  and  the 
fibrous  or  sarcomatous  polyp  that  usually  takes  origin 
from  the  periosteum  of  the  nasal  roof,  or  from  that  of  the 


Chap.  VI.]          NOSE   AND    NASAL     CAVITIES.  93 

base  of  the  skull.  Polypi  of  the  latter  kind  spread  in 
every  available  direction.  They  expand  the  bridge  of 
the  nose,  close  the  nasal  duct  and  cause  epiphora, 
depress  the  hard  palate,  and  encroach  upon  the  mouth, 
invade  the  antrum  and  expand  the  cheek,  grow  down 
into  the  pharynx,  pushing  forwards  the  velum  palati, 
and  may  penetrate  even  through  the  inner  wall  of  the 
orbit.  In  one  remarkable  case  quoted  in  the  Lancet 
for  1877,  a  tumour  springing  from  the  sheath  of  the 
superior  maxillary  nerve  just  after  its  exit  from  the 
foramen  rotundum,  pi-qjocted  into  the  nasal  fossae.  It 
was  mistaken  for  a  polyp,  and  attempts  to  remove  it 
led  to  meningitis  and  death. 

The  blood  supply  of  the  nasal  cavity  is  exten- 
sive, and  is  derived  from  the  internal  maxillary, 
ophthalmic,  and  facial  arteries.  With  regard  to  the 
veins,  it  may  be  noted  that  the  ethmoidal  veins  that 
come  from  the  nose  enter  the  ophthalmic  vein,  while 
in  children  a  constant  communication  exists  between 
the  nasal  veins  and  the  superior  longitudinal  sinus 
through  the  foramen  caecum.  This  communication 
may  also  be  maintained  in  the  adult.  These  connec- 
tions may,  in  part,  serve  to  explain  the  occurrence  of 
intracranial  mischief  as  a  consequence  of  certain  in- 
flammatory affections  of  the  nasal  cavities.  Bleeding 
from  the  nose,  or  epistaxis,  is  a  common,  and  often  a 
serious  circumstance.  Its  frequency  is  to  a  great  ex- 
tent due  to  the  vascularity  of  the  mucous  membrane, 
to  its  laxity,  and  to  the  fact  that  the  veins,  especially 
those  over  the  lowest  turbinate  bone,  form  extensive 
plexuses,  and  pi'oduce  a  kind  of  cavernous  tissue.  The 
epistaxis  is  often  due,  therefore,  to  interference  with 
the  venous  circulation,  as  seen  in  cases  of  cervical 
tumour  pressing  upon  the  great  veins,  in  the  paroxysms 
of  whooping  cough,  and  the  like.  The  beneficial 
effect  of  raising  the  arms  in  epistaxis  is  supposed  to 
depend  upon  the  extra  expansion  of  the  thorax  thus 


94  SUKGICAL  APPLIED  ANATOMY.      [Chap,  vi 

produced,  and  the  aspiratory  effect  thus  brought  to 
bear  upon  the  cervical  veins.  The  bleeding  may  be 
copious  and  long  continued.  Thus  Spencer  Watson 
reports  a  case  where  the  epistaxis  continued  on  and  off 
for  twenty  months  without  obvious  cause.  Martineau 
mentions  an  instance  in  which  12  Ibs.  of  blood  were 
lost  in  sixty  hours,  and  FVaenkel  records  a  case  where 
75  Ibs.  of  blood  are  said  to  have  escaped  from  first  to 
last.  In  several  instances  the  haemorrhage  has  proved 
fatal.  The  seat  of  the  bleeding  is  often  not  easy  to 
detect,  even  when  the  examination  is  post  mortem. 

The  nerve  supply  of  these  parts  is  derived  from 
the  olfactory  nerve,  and  from  the  first  and  second 
divisions  of  the  fifth  nerve.  The  lachrymation  that 
often  follows  the  introduction  of  irritants  into  the 
front  of  the  nares,  may  be  explained  by  the  fact  that 
that  part  of  the  cavity  is  supplied  freely  by  the  nasal 
nerve,  a  branch  of  the  ophthalmic  ti'unk.  As  an  ex- 
ample of  transference  of  nerve  force  in  the  opposite 
direction,  may  be  noted  cases  where  a  strong  sunlight 
falling  upon  the  eyes  has  produced  an  attack  of  sneezing. 
Troubles  involving  the  vagus  nerve,  such  as  cough 
and  bronchial  asthma,  have  followed  affections  of  the 
nasal  cavities.  The  olfactory  nerves  are  situated  high 
up  in  the  cavity,  and  thus,  in  smelling  intently,  the 
individual  sniffs  deeply  and  dilates  the  nostril.  The 
inability  to  dilate  the  nostril  in  facial  paralysis,  may 
explain  the  partial  loss  of  smell  sometimes  noted  in 
such  cases.  It  is  said  (Althaus)  that  anosmosia,  or  loss 
of  the  sense  of  smell,  when  following  upon  an  injury 
to  the  head,  may  be  due  to  a  rupture  of  the  olfactory 
nerve  fibres,  as  they  pass  through  the  cribriform  fora- 
mina. Surgery  affords  some  examples  of  the  possible 
violence  of  the  act  of  sneezing.  Thus  a  man  sneezed 
vigorously  when  his  hand  was  firmly  supported  upon 
an  object,  and  produced  a  subcoracoid  dislocation  of 
his  shoulder  (Lancet,  1878).  In  another  case,  the 


CV.ap.  VI.]         NOSE  AND    NASAL    CAVITIES.  95 

ninth  rib  on  the  left  side  was  fractured  during  a  fit  of 
sneezing  (Med.  Times,  1862).  Mr.  Pitts  (Lancet, 
1883)  has,  However,  reported  the  strangest  case  of  all, 
a  case  in  which  all  the  coverings  of  a  large  femoral 
hernia  were  ruptured  during  the  act  of  sneezing,  so 
that  the  bowels  escaped. 

Some  of  the  lymphatics  of  the  nasal  fossae  enter 
certain  glands  placed  behind  the  pharynx,  in  front  of  the 
rectus  capitis  anticus  major.  Hence,  as  Fraenkel  has 
pointed  out,  "  retro-pharyngeal  abscess  may  arise  in 
consequence  of  diseases  of  the  nose."  Other  lympha- 
tics go  to  the  submaxillary  and  parotid  lymph  glands, 
and  it  is  common  to  find  the  former  set  of  glands  en- 
larged in  nose  affections,  especially  in  the  scrofulous. 

The  sinuses. — These  may  be  briefly  dealt  with. 
The  frontal  sinuses  are  not  present  in  early  youth,  but 
develop  as  age  advances.  They  do  not  exist  before 
the  age  of  10  years,  but  are  well  developed  by  20. 
They  are  practically  formed  from  the  diploe.  Large 
frontal  sinuses  do  not  necessarily  imply  large  ex- 
ternal prominences  over  the  glabella  and  superciliary 
eminences.  They  often  develop  more  as  the  brain 
shrinks,  and  appear  then  to  follow,  as'  it  were,  the 
receding  brain.  Bony  tumours  often  grow  from  the 
interior  of  these  sinuses,  and  are  known  as  enostoses. 
It  is  obvious  that  a  depressed  fracture  may  exist  over 
a  frontal  sinus,  without  the  cranial  cavity  being 
damaged.  In  such  cases,  the  inspissated  contents  of 
the  sinus  have  been  mistaken  for  brain  matter  escap- 
ing. Since  the  sinuses  communicate  with  the  nose, 
much  emphysema  may  follow  upon  fracture  of  the 
sin  us  wall.  Insects  have  found  their  way  into  these 
cavities.  "  Centipedes  are  particularly  liable  to  be 
found  in  the  frontal  sinuses,  where  they  may  remain  for 
years,  the  secretions  of  these  cavities  furnishing  them 
with  sufficient  nourishment  "  (Fraenkel).  Larvae  have 
also  been  found  here,  and  maggots  that  have  developed 


96  SURGICAL  APPLIED  ANATOMY,      tchap. vi. 

within  the  nose  have  managed  to  make  their  way  to 
the  frontal  sinuses.  A  case  is  reported  where  epis- 
taxis,  extending  over  many  years,  was  due  to  an  insect 
(the  pentastoma  tfenioides)  that  had  settled  in.  these 
sinuses.  One  day  it  was  sneezed  out,  and  no  further 
bleeding  occui'red  (Med.  Times,  1876).  The  last-named 
parasite  is  said  to  be  often  met  with  in  the  frontal 
sinus  of  the  dog.  The  antrum  exists  at  birth,  but 
attains  its  largest  dimensions  in  old  age.  The  walls  of 
the  cavity  are  thicker  in  children  than  in  adults. 
Tumours  of  various  kinds  are  apt  to  develop  in  this 
cavity,  and  to  distend  its  walls  in  various  directions. 
Thus  the  growth  breaks  through  the  thin  inner  wall 
and  invades  the  nose,  it  pushes  up  the  roof  of  the 
cavity  and  invades  the  orbit,  it  encroaches  upon  the 
mouth  through  the  floor  of  the  antrum,  and  makes  its 
way  also  through  the  somewhat  slender  anterior  wall 
into  the  cheek.  The  densest  part  of  the  antrum  wall 
is  that  in  relation  to  the  malar  bone,  and  this  part 
does  not  yield.  There  is  little  inducement  for  any 
growth  to  spread  backwards,  although  it  sometimes 
invades  the  zygomatic  and  pterygo-maxillary  fossae. 
As  the  infraorbital  nerve  runs  along  the  roof  of  the 
antrum,  while  the  nerves  of  the  upper  teeth  are  con- 
nected with  its  walls,  these  structures  are  pressed 
upon  in  growths  springing  from  the  antrum,  and 
much  neuralgia  of  the  face  and  teeth  often  produced. 
In  tapping  the  antrum,  a  spot  is  usually  selected  just 
above  the  second  bicuspid  tooth,  since  the  bone  is  here 
thin  and  is  conveniently  reached.  In  some  cases  it  is 
sufficient  to  extract  a  molar  tooth,  since  the  fangs  of 
these  teeth  often  enter  the  cavity  of  the  antrum. 
The  teeth  usually  selected  are  either  the  first  or  the 
third  molar. 

As  the  result  of  a  fall,  one  of  the  upper  teeth  has 
been  entirely  driven  into  the  antrum  and  lost  to  view. 
In  one  case,  reported  by  Haynes  Walton,  an  upper 


chap.  VIM  THE  FACE.  97 

incisor  was  found  lying  loose  in  the  antrum  three 
and  a  half  years  after  the  accident  that  had  driven  it 
there. 


CHAPTER  VII. 

THE  FACE. 

THE  parts  of  the  face,  other  than  those  already 
dealt  with,  will  be  considered  under  the  following 
lueads  :  (1)  The  face  generally ;  (2)  the  parotid 
region  ;  and  (3)  the  upper  and  lower  jaws  and  parts 
connected  with  them.  The  lips  will  be  considered 
with  the  "cavity  of  the  mouth"  (chap.  viii). 

1.  The  face  generally.— The  skin  of  the  face 
is  thin  and  fine,  and  is  more  or  less  intimately  adhe- 
rent by  a  delicate  subcutaneous  tissue  to  the  parts 
beneath.  The  skin  generally  is  very  freely  supplied 
with  sebaceous  and  sudoriparous  glands,  and  hence 
the  face  is  very  commonly  the  seat  of  acne,  an  erup- 
tion that  specially  involves  the  sebaceous  follicles.  It 
happens  from  the  thinness  of  the  skin,  and  from  the 
absence  of  dense  fasciae,  that  facial  abscesses  usually 
soon  point  and  seldom  attain  large  size. 

The  cellular  tissue  of  the  face  is  lax,  and  readily 
lends  itself  to  spreading  infiltrations,  so  that  in 
certain  inflammatory  affections  the  cheeks  and  other 
parts  of  the  face  may  become  greatly  swollen.  In 
general  dropsy,  also,  the  face  soon  becomes  "  puffy," 
the  change  first  appearing,  as  a  rule,  in  the  lax  tissue 
of  the  lower  lid.  The  skin  over  the  chin  is  peculiarly 
dense  and  adherent  to  the  parts  beneath,  and  in  most 
respects  closely  resembles  the  integument  of  the  scalp. 
When  such  parts  of  the  integuments  of  the  face  as 
cover  prominent  bones,  such  as  the  parts  over  the 
H— 4 


9°  SURGICAL  APPLIED  ANA  TOMY.    [Chap.  vn. 

malar  bone,  the  chin,  the  upper  lid,  are  struck  by  a 
blunt  instrument  or  in  a  fall,  the  wound  produced 
has  often  the  appearance  of  a  clean  incised  wound, 
just  as  obtains  in  contused  wounds  of  the  scalp. 

The  mobility  of  the  facial  tissues  renders  this 
part  very  suitable  for  the  performance  of  plastic 
operations  of  various  kinds,  and  their  Yascularity 
generally  insures  a  ready  and  sound  healing.  Al- 
though there  is  a  large  quantity  of  fat  in  the  subcu- 
taneous tissue  in  this  region,  yet  fatty  tumours  are 
singularly  rare  upon  the  face.  They  appear,  indeed, 
to  avoid  this  region.  Thus  M.  Denay  reports  the  case 
of  a  man  who  had  no  less  than  215  fatty  tumours 
over  different  parts  of  his  body,  but  not  one  upon  his 
face.  The  thickness  of  the  tissues  of  the  cheek  and 
lips  favour  the  embedding  of  foreign  substances  in 
those  parts.  Thus,  a  tooth  that  has  been  knocked 
out  has  remained  for  some  time  embedded  in  the  lip. 
Henry  Smith  reports  a  remarkable  case,  where  he 
removed  a  piece  of  tobacco-pipe  three  inches  long  from 
the  cheek,  in  the  tissues  of  which  it  had  been  em- 
bedded for  several  years.  The  soft  tissues  of  the 
cheek  greatly  favour  the  spread  of  destructive  pro- 
cesses. Thus  in  cancrum  oris,  a  form  of  gangrene  of 
the  face  attacking  the  young,  the  whole  cheek  may 
be  lost  in  a  few  days.  Great  contraction  is  apt  to 
follow  upon  loss  of  substance  in  the  cheek,  so  that  in 
some  cases  the  jaws  may  be  firmly  closed,  as  is  seen  after 
recovery  from  advanced  cancrum  oris.  The  face  is 
peciiliarly  liable  to  be  the  seat  of  certain  ulcers,  espe- 
cially the  rodent  and  lupoid  ulcer,  and  is  the  part 
most  often  attacked  by  "  malignant  pustule,"  a  disease 
transmitted  to  man  from  cattle  afflicted  with  a  malady 
known  in  this  country  as  "  murrain,"  and  in  France  as 
"  charbon." 

Blood  supply. — The  tissues  of  the  face  are  very 
vascular,  and  are  liberally  supplied  with  blood- vesse?s  in 


chap,  vii.i  THE  FACR.  99 

all  parts.  The  finer  vessels  of  the  skin  often  appear  per- 
manently injected  or  varicose  in  the  drunken,  or  in  those 
who  are  exposed  to  cold,  or  are  the  subjects  of  certain 
forms  of  acne.  Thus,  nsevi,  and  the  various  forms  of 
erectile  tumour,  are  common  about  the  face.  For  a 
like  reason  also  wounds  of  the  face,  while  they  may 
bleed  readily  when  inflicted,  are  apt  to  heal  with 
singular  promptness  and  accuracy.  All  wounds, 
therefore,  of  this  part  should  have  their  edges  care- 
fully adjusted  as  soon  after  the  accident  as  possible. 
Extensive  flaps  of  skin  that  have  been  torn  up  in 
lacerated  wounds  often  retain  their  vitality  in  almost 
as  marked  a  manner  as  do  like  flaps  torn  up  from  the 
scalp.  Extensive  injuries  of  the  face  associated  with 
great  loss  of  substance  are  often  repaired  in  a  most 
remarkable  manner,  as  has  been  illustrated  in  gunshot 
wounds,  where  a  considerable  portion  of  the  face  and 
upper  jaws  has  been  blown  away.  The  low  mortality 
after  severe  injuries  to  the  face  is  due,  however,  not 
only  to  the  excellent  powers  of  repair  the  part  pos- 
sesses, but  also  to  the  fact  that  the  face  contains  no 
organs  essential  to  life,  that  its  bones  are  soft  and  thin 
and  do  not  favour  extensive  splitting,  and  that  there 
are  several  passages  and  cavities  in  the  region  through 
which  discharges  may  escape.  One  of  the  most 
terrible  instances  of  injury  not  immediately  fatal  is 
reported  by  Longmore :  "  An  officer  of  Zouaves, 
wounded  in  the  Crimea,  had  his  whole  face  and  lower 
jaw  carried  away  by  a  ball,  the  eyes  and  tongue  in- 
cluded, so  that  there  remained  only  the  cranium,  sup- 
ported by  the  neck  and  spine."  He  lived  twenty 
hours. 

The  pulsations  of  the  facial  artery  can  be  best  felt 
at  the  lower  border  of  the  jaw,  where  the  vessel 
crosses  just  in  front  of  the  anterior  border  of  the 
masseter  muscle.  It  is  here  covered  only  by  the  integu- 
ment and  platysnia,  and  can  be  readily  compressed 


ioo  SURGICAL  APPLIED  ANATOMY,     rchap.  vn. 

against  the  bone,  or  ligatured.  The  anastomoses  of  the 
artery  upon  the  face  are  so  free,  that,  when  the  vessel 
is  divided,  both  ends,  as  a  rule,  require  to  be  secured. 
The  facial  vein  is  only  in  contact  with  the  artery  near 
the  lower  border  of  the  jaw ;  on  the  face  it  is  sepa- 
rated from  it  by  a  considerable  interval.  The  vein  is 
not  so  flaccid  as  are  most  superficial  veins;  it  remains 
more  patent  after  section,  it  possesses  no  valves, 
and  communicates  at  one  end  indirectly  with  the 
cavernous  sinus,  and  at  the  other  with  the  internal 
jugular  vein  in  the  neck.  This  vein  has  also  another, 
but  less  direct,  communication  with  the  intracranial 
veins.  It  is  as  follows :  the  facial  vein  receives  the 
"  deep  facial  vein "  from  the  pterygoid  plexus,  and 
this  plexus  communicates  with  the  cavernous  sinus  by 
means  of  some  small  veins  which  pass  through  the 
foramen  ovale  and  the  fibrous  tissue  of  the  foramen 
lacerum  rnedius.  These  dispositions  of  the  facial  vein 
may  serve  to  explain  the  mortality  of  some  inflamma- 
tory affections  of  the  part.  Thus,  carbuncle  of  the  face 
is  not  unf  requently  fatal  by  inducing  thrombosis  of  the 
cerebral  sinuses,  and  a  like  complication  may  occur  in 
any  other  diffuse  and  deeply-extending  inflammatory 
condition.  The  unusual  patency  also  of  the  facial 
vein  favours  septic-  absorption,  and  its  direct  commu- 
nication with  the  great  vein  in  the  neck  may  explain 
those  abrupt  deaths  from  thrombosis  that  have  fol- 
lowed upon  the  injection  of  facial  nsevi  in  infants. 

Nerve  supply. — The  nerves  of  the  face  are  very 
liberally  distributed,  the  fifth  being  the  sensory  nerve, 
the  facial  the  motor.  It  follows,  from  the  great 
number  of  nerve  filaments  about  the  part,  that  severe 
irritants  applied  to  the  face  may  set  up  a  widespread 
nerve  disturbance.  Dr.  George  Johnson  mentions  a 
case  where  a  piece  of  flint  embedded  in  a  scar  on  the 
cheek  set  up  facial  neuralgia,  facial  paralysis,  and 
trismus,  and  induced  a  return  of  epileptic  attacks.  The 


chap,  vii.i  THE  FACE.  101 

positions  of  the  supra-  and  infraorbital  foramina  and 
of  the  mental  foramen  are  indicated  as  follows.  The 
supraorbital  foramen  is  found  at  the  junction  of  the 
inner  with  the  middle  third  of  the  upper  margin  of  the 
orbit.  A  straight  line  drawn  downwards  from  this 
point  so  as  to  cross  the  gap  between  the  two  bicus- 
pids in  both  jaws,  will  hit  both  the  infraorbital  and 
mental  foramina.  The  infraorbital  foramen  is  a  little 
over  a  quarter  of  an  inch  below  the  margin  of  the 
orbit.  The  dental  foramen  in  the  adult  is  midway 
between  the  alveolus  and  the  lower  border  of  the 
jaw,  and  is  a  little  over  a  quarter  of  an  inch  below 
the  cul-de-sac  of  mucous  membrane  between  the  lower 
lip  and  jaw.  At  puberty  the  foramen  is  nearer  to  the 
lower  border  of  the  maxilla,  and  in  old  age  it  is  close 
to  the  alveolus.  The  infraorbital  nerve  has  been 
divided  for  neuralgia  at  its  point  of  exit,  the  nerve 
being  reached  either  by  external  incision  or  through 
the  mouth  by  lifting  up  the  cheek.  In  other  cases  the 
floor  of  the  orbit  has  been  exposed,  the  infraorbital 
canal  (the  anterior  half  of  which  has  a  bony  roof)  has 
been  opened  up,  and  large  portions  of  the  trunk  of 
the  nerve  have  been  in  this  way  resected.  Meckel's 
ganglion  has  been  repeatedly  excised  for  the  relief  of 
neuralgia  involving  the  second  division  of  the  fifth 
nerve.  A  triangular  flap  of  skin  is  turned  up  from 
the  front  of  the  cheek,  and  the  infraorbital  canal  is 
exposed.  The  anterior  wall  of  the  antrum  is  opened 
with  a  trephine,  and  the  bone  is  cut  away  from  the 
floor  of  the  infraorbital  groove  so  that  the  nerve  lying 
in  that  canal  is  fully  exposed.  The  nerve  is  followed 
back  to  the  posterior  wall  of  the  antrum.  This  wall 
having  been  trephined,  the  spheno-maxillary  fossa  is 
opened  up  and  Meckel's  ganglion  exposed.  Beyond 
the  ganglion  the  foramen  rotundum  can  be  made  out. 
The  infraorbital  artery  runs  with  the  nerve,  and  that 
vessel,  together  with  its  anterior  dental  branch  to  the 


2O2  SURGICAL  APPLIED  ANATOMY.    [Chap.  vn. 

incisor  and  canine  teeth,  will  probably  be  divided. 
The  infraorbital  vein  ends  in  the  pterygoid  plexus. 
The  ganglion  is  surrounded  by  the  terminal  branches 
of  the  internal  maxillary  artery.  It  is  a  triangular 
body,  with  a  diameter  of  about  one-fifth  of  an  inch. 
It  is  a  little  convex  on  its  outer  side,  and  is  of  a  red- 
dish colour. 

The  following  are  the  relations  of  the  ganglion  : 

Above. 
The  second  division  of  the  fifth  nerve. 

Outer  side.  Inner  side. 
Termination  of  internal  J?I«»Clcel'S         Vertical  plate  of  palate, 
maxillary  artery.  Spheno  -  palatine    fora- 
External  pterygoid  gaJlgllOIl.                         men. 
muscle.                   

Behind. 
Vidian  canaL 
Sphenoid  bono. 

The  inferior  dental  nerve  has  been  divided  at 
the  mental  foramen  by  an  incision  made  through  the 
mucous  membrane.  Through  this  incision  the  nerve 
can  be  stretched  and  the  cutaneous  portion  of  it  ex- 
cised. Its  trunk  has  been  reached,  and  a  part  excised 
through  a  trephine  hole  made  in  the  body  of  the 
lower  jaw.  This  operation,  however,  inflicts  great 
damage  upon  the  bone,  and  cannot  be  recommended. 
The  artery,  moreover,  is  liable  to  be  wounded. 

The  nerve  has  been  divided  also  before  its 
entry  into  the  dental  foramen  in  the  following 
manner :  The  mouth  being  held  widely  open,  an 
incision  is  made  from  the  last  upper  molar  to  the 
last  lower  molar  just  to  the  inner  side  of  the 
anterior  border  of  the  coronoid  process.  The  cut 
passes  through  the  mucoiis  membrane  down  to  the 
tendon  of  the  temporal  muscle.  The  finger  is 
introduced  into  the  incision,  and  passed  between 
the  ramus  of  the  jaw  and  the  internal  pterygoid 
muscle  until  the  bony  point  is  felt  that  marks  the 


Chap,  vii.]  THE  FACE.  103 

orifice  of  the  dental  canal.     The  nerve  is  here  picked 
up  with  a  hook,  isolated,  and  divided. 

The  buccal  nerve  may  be  the  seat  of  severe  neu- 
ralgia, and  may  be  thus  divided  through  the  mouth  : 
"The  surgeon  places  the  finger-nail  iipon  the  outer  lip 
of  the  anterior  border  of  the  ascending  ram  us  of  the 
lower  jaw  at  its  centre,  and  divides  in  front  of  this  bor- 
der the  mucous  membrane  and  the  fibres  of  the  buccina- 
tor vertically.  He  then  seeks  for  the  nerve,  separating 
the  tissues  with  a  director,  and  divides  it "  (Stimson). 

The  trunk  of  the  third  division  of  the  fifth  nerve 
has  been  divided  at  the  foramen  ovale  through  a  flap 
wound  made  in  the  cheek.  Considerable  damage  of 
the  soft  parts  results. 

Mr.  Wm.  Rose  has  removed  the  Gasserian  ganglion 
for  intractable  neuralgia.  A  flap  is  made  in  the  cheek. 
The  zygomaand  coronoid  process  of  the  jaw  are  divided, 
and  the  masseter  and  temporal  muscles  turned  aside ; 
the  external  pterygoid  muscle  is  next  divided,  and  the 
bone  around  the  foramen  ovale  removed  with  a 
trephine.  There  is  much  bleeding.  In  the  first  case 
the  eye  sloughed. 

Tne  malar  bone. — Such  is  the  firmness  of  this 
bone,  and  so  direct  is  its  connection  with  the  skull, 
that  violent  blows  upon  it  are  very  apt  to  be  associated 
T/ith  concussion.  Resting  as  it  does  upon  com- 
paratively slender  bones,  it  is  very  rare  for  the  malar 
bone  to  be  broken  alone.  It  may,  indeed,  be  driven 
into  the  superior  maxillary  bone,  fracturing  that 
structure  extensively,  without  being  itself  in  any  way 
damaged.  A  fracture  of  the  malar  bone  may  lead  to 
an  orbital  ecchymosis,  precisely  like  that  which  often 
attends  a  fracture  of  the  skull  base. 

2.  The  parotid  region. — The  main  part  of  the 
parotid  gland  is  lodged  in  a  definite  space  behind  the 
ranms  of  the  lower  jaw.  This  space  is  increased  in 
size  when  the  head  is  extended,  and  when  the  inferior 


io4  SURGICAL  APPLIED  ANATOMY.     [Chap,  vn 

maxilla  is  moved forwards,  as  in  protruding  the  chin.  In 
the  latter  movement,  the  increase  intheantero-posterior 
direction  is  equal  to  about  three-eighths  of  an  inch. 
It  is  diminished  when  the  head  is  flexed.  When  the 
mouth  is  widely  opened  the  space  is  diminished  below, 
while  it  is  increased  above  by  the  gliding  forwards  of 
the  condyle.  These  facts  should  be  borne  in  mind 
in  operating  upon  and  in  exploring  the  parotid  space. 
It  will  be  found  also  that  in  inflammation  of  the 
parotid  much  pain  is  produced  by  all  those  move- 
ments that  tend  to  narrow  the  space  occupied  by  the 
gland.  The  obliquity  of  the  ramus  of  the  jaw  in 
infancy  and  old  age  causes  the  lower  part  of  the  space 
to  be,  in  the  former  instance  relatively,  and  in  the 
latter  instance  actually,  larger  than  it  is  in  the  adult. 
The  gland  is  closely  invested  by  a  fascia  derived 
from  the  cervical  fascia.  The  superficial  layer  of  the 
parotid  fascia  is  very  dense,  is  continuous  behind  with 
the  fibrous  sheath  of  the  sterno-mastoid,  and  in  front 
with  that  of  the  masseter.  Above  it  is  attached  to 
the  zygoma,  while  below  it  joins  the  deep  layer.  The 
deep  layer  is  slender,  is  attached  to  the  styloid  process, 
forms  the  stylo-maxillary  ligament,  and  is  connected 
with  the  sheaths  of  the  pterygoid  muscles  and  the 
pterygoid  process.  The  gland  is,  therefore,  encased 
in  a  distinct  sac  of  fascia,  which  is  entirely  closed 
below,  but  is  quite  open  above.  Between  the  anterior 
edge  of  the  styloid  process  and  the  posterior  border 
of  the  external  pterygoid  muscle  there  is  a  gap  in 
the  fascia,  through  which  the  parotid  space  communi- 
cates with  the  connective  tissue  about  the  pharynx. 
It  is  well  known  that  in  post-pharyrgeal  abscesses 
there  is  very  usually  a  parotid  swelling,  and  in  several 
instances  the  pus,  or  at  least  some  portion  of  it,  has 
been  evacuated  in  the  parotid  region.  In  these  cases 
the  matter  most  probably  extends  from  the  pharyngeal 
to  the  parotid  region,  through  the  gap  just  described. 


Chap.  VII.] 


THE  FACE. 


From  the  disposition  of  the  fascia  it  follows  that  very 
great  resistance  is  offered  to  the  progress  of  a  parotid 


Fig1.  13.— A  Horizontal  Section  through  the  Pace  and  Neck  just  above 
the  level  of  the  Lower  Teeth  (Braune). 

a,  Orbicularig  oris  and,  behind  it,  the  buccinator ;  b,  internal  pterygoid ;  e,  mas- 
setcr ;  d,  stylo-glossus,  stylo-pbarynjreus,  and  styloid  process;  e.,  splenius 
rapitis;/,  digastric;  g,  sterno-nmstoid ;  ft,  obliquus  superior;  i,  trachclo- 
mastoid  ; ),  biventer  cervicisand  roruplexus  ;  t,  trapezius;  {.tonsil;  m,  facial 
artery  ;  n,  facial  vein  ;  o,  gustatorj'  nerve  ;  j>,  inferior  dental  nerve  and  artery  ; 

0,  styloid  process ;  r,  external  carotid  artery ;  »,  internal  carotid  artery : 

1,  vagus  ;  tr,  parotid  gland  ;  x,  internal  jugular  vein,  with  the  vagus,  spinal 
accessory,  and  hypo-glossal  nerves  to  us  inner  side ;  v,  vertebral  artery  : 
«,  odontoid  process;  1,  occipital  artery. 


ro6  SURGICAL  APPLIED  ANATOMY,     rchap. vn. 

abscess  directly  outwards  through  the  skin.  The 
abscess  often  advances  upwards  to  the  temporal,  or 
zygotnatic  fossje,  in  the  direction  of  least  resistance, 
although  progress  in  that  line  is  resisted  by  gravity. 
It  frequently  makes  its  way  towards  the  buccal 
cavity  or  pharynx,  or  it  may  break  through  the 
lower  limits  of  the  fascia  and  reach  the  neck.  It 
must  be  borne  in  mind  that  the  gland  is  in  direct 
contact  with  the  cartilaginous  meatus,  with  the  ramus 
of  the  jaw  and  other  bony  parts,  and  is  closely 
related  with  the  temporo-maxillary  joint.  Thus,  a 
parotid  abscess  has  burst  into  the  nieatus,  has  led  to 
periostitis  of  the  bones  adjacent  to  it,  and  has  incited 
inflammation  in  the  joint  of  the  lower  jaw. 

In  several  cases  reported  by  Virchow  the  pus 
appears  to  have  found  its  way  into  the  skull  along 
branches  of  the  fifth  nerve,  for  the  environs  of  the 
Gasserian  ganglion  were  found  infiltrated  with  pus. 
The  auriculo-temporal  and  great  auricular  nerves  sup- 
ply the  gland  with  sensation,  and  the  presence  of  these 
nerves,  together  with  the  unyielding  character  of  the 
parotid  fascia,  serve  to  explain  the  great  pain  felt  in 
rapidly  growing  tumours  and  acute  inflammation  of  the 
gland.  The  pain  is  often  very  distinctly  referred  along 
the  course  of  the  auriculo-temporal  nerve.  Thus,  a 
patient  with  a  parotid  growth,  recently  under  my  care, 
had  pain  in  those  parts  of  the  pinna  and  temple  supplied 
by  the  nerve,  pain  deep  in  the  meatus,  at  a  spot  that 
would  correspond  to  the  entrance  of  the  meatus  branch 
of  the  nerve,  and  pain  in  the  joint  of  the  lower  jaw, 
which  is  supplied  by  the  auriculo-temporal. 

The  most,  important  structures  in  the  gland  are 
the  external  carotid  artery,  with  its  two  terminal 
branches,  and  the  facial  nerve.  The  artery,  as 
Tilla«x  has  pointed  out,  is  behind  the  ramus  of  the 
jaw,  as  high  up  as  the  junction  of  the  inferior  with 
the  middle  third  of  its  posterior  border.  It  then 


Chap  VIM  THE  FACE.  107 

enters  tho  parotid  gland,  and,  passing  a  little  back- 
wards and  outwards,  comes  nearer  to  the  surface, 
and  at  the  level  of  the  condyle  of  the  jaw  breaks 
into  its  two  terminal  branches.  The  artery,  there- 
fore, does  not  enter  the  gland  at  its  inferior  border, 
and  is  not  in  actual  relation  with  the  parotid  space 
at  its  lowest  part.  The  vessel,  moreover,  is  not 
parallel  with  the  edge  of  the  ramus,  but  passes 
through  the  parotid  gland  with  some  obliquity. 

The  facial  nerve  is  represented  by  a  line  drawn 
across  the  gland,  in  a  direction  forwards  and  a 
little  downwards  from  the  spot  where  the  anterior 
border  of  the  mastoid  process  meets  the  ear.  The 
nerve  is  not  quite  so  intimately  bound  up  in  the 
gland  as  is  the  carotid  artery,  and  in  rapidly  growing 
tumours  of  the  gland  facial  paralysis  from  pressure 
upon  this  nerve  is  not  uncommon. 

The  nerve  has  been  stretched  close  to  its  point  of  exit 
from  the  stylo-mastoid  foramen  for  the  relief  of  facial 
tic.  It  is  best  found  at  a  spot  about  a  quarter  of  an  inch 
in  front  of  the  centre  of  the  anterior  border  of  the 
mastoid  process. 

It  follows,  from  the  complex  relations  of  the  parotid, 
that  its  entire  removal  as  a  surgical  procedure  is  an 
anatomical  impossibility.  In  opening  a  parotid  abscess 
a  cut  is  usually  made  over  the  angle  of  the  jaw,  and 
a  director  pushed  upwards  into  the  substance  of  the 
gland,  after  the  plan  advised  by  Hilton.  The  gland  is 
separated  by  a  mere  layer  of  fascia  from  the  internal 
carotid  artery,  the  internal  jugular  vein,  the  vagus, 
glosso  pharyngeal,  and  hypoglossal  nerves  (Fig.  13). 
Thus,  in  stabs  in  the  parotid  region  it  may  be  difficult 
at  first  to  tell  whether  the  internal  or  the  external 
carotid  is  wounded.  It  has  been  suggested  that  the 
cerebral  hypersemia,  sometimes  noticed  in  severe  paro- 
titis (mumps),  may  be  due  to  the  pressure  of  the 
enlarged  gland  upon  the  internal  jugular  vein. 


io8  SURGICAL  APPLIED  ANATOMY.     [Chap.vn. 

Tumours  of  the  parotid  are  very  apt  to  contain 
cartilaginous  tissue.  It  is  well  known  that  metas- 
tases  after  mumps  are  quite  common  in  the  testis. 
It  is  significant  in  this  connection  that  the  testis  is 
one  of  the  few  parts  of  the  body,  apart  from  bone, 
where  cartilaginous  matter  forms  a  frequent  con- 
stituent of  the  neoplasms  of  the  part.  Mr.  Paget  has 
pointed  out  that  inflammation  of  the  parotid  is 
peculiarly  frequent  after  injuries  and  diseases  of  the 
abdomen  and  pelvis.  It  occurs  also  very  often  as  a 
sequela  of  some  specific  fevers,  but  more  especially 
after  typhoid.  The  anatomical  or  physiological  basis 
of  this  connection  has  not  been  made  out. 

Many  lymphatic  glands  are  placed  upon  the 
surface  and  in  the  substance  of  the  parotid  gland. 
They  receive  lymph  from  the  frontal  and  parietal  re- 
gions of  the  scalp,  from  the  orbit,  the  posterior  part 
of  the  nasal  fossae,  the  upper  jaw,  and  the  hinder  and 
upper  part  of  the  pharynx.  When  enlarged  these 
glands  may  form  one  species  of  "  parotid  tumour." 

Stenson's  duct  is  about  two  and  a  half  inches 
long,  and  has  a  diameter  of  one-eighth  of  an  inch,  its 
orifice  being  the  narrowest  part.  At  the  anterior 
border  of  the  masseter  muscle  the  duct  bends  sud- 
denly inwards  to  pierce  the  buccinator  muscle.  The 
bend  is  so  abrupt  that  the  buccal  segment  of  the  duct 
may  be  almost  at  right  angles  with  the  masseteric. 
This  bend  should  be  taken  into  consideration  in 
passing  a  probe  along  the  duct  from  the  mouth.  The 
duct  opens  on  the  summit  of  a  papilla  placed  on  a 
level  with  the  second  upper  molar  tooth.  The  course 
of  the  duct  across  the  masseter  is  represented  by  a  line 
drawn  from  the  lower  margin  of  the  concha  to  a  point 
midway  between  the  ala  of  the  nose  and  the  red 
margin  of  the  lip.  It  lies  about  a  finger-breadth 
below  the  zygoma,  having  the  transverse  facial  artery 
above  it  and  the  facial  nerve  below  it.  The  duct  has 


chap.vn.j  THE  FACE.  109 

been  ruptured  subcutaneously,  leading  to  extravasa- 
tion of  saliva.  Wounds  of  the  duct  are  apt  to  lead  to 
salivary  fistulas.  When  the  fistula  involves  the  buccal 
segment  of  the  duct  it  may  be  cured  by  opening  the 
duct  into  the  mouth  on  the  proximal  side  of  the 
fistula.  Fistulse  of  the  masseteric  segment  are,  on  the 
other  hand,  very  difficult  to  relieve.  At  least  one-half 
of  the  buccal  part  of  the  duct  is  embedded  in  the 
substance  of  the  buccinator  muscle.  A  salivary  fistula 
over  the  masseter  may  involve  the  parotid  gland 
itself,  or  that  part  of  it  known  as  the  socia  parotid  is. 
Inflammatory  conditions  may  spread  to  the  parotid 
from  the  mouth  along  Stenson's  duct. 

3.  The  upper  and  lower  jaws,  and  parts 
connected  with  them. 

The  superior  maxilla  (for  antrum,  see  Nose, 
page  96 ;  for  hard  palate,  see  Mouth,  page  129). 
— This  bone,  on  account  of  its  fragility,  and  the 
manner  in  which  it  is  hollowed  out,  is  very  readily 
fractured.  The  fracture  may  be  due  to  direct  violence, 
as  by  a  blow  from  a  "  knuckle-duster,"  or  it  may 
be  broken  by  a  force  transmitted  from  the  lower 
jaw  through  the  teeth,  as  in  cases  of  severe  blows  or 
falls  upon  the  chin.  It  may  be  broken  by  a  blow 
upon  the  head,  when  the  chin  is  fixed,  no  other  bone 
being  damaged ;  and,  lastly,  it  may  be  crushed,  as 
above  stated,  by  the  driving  in  of  the  malar  bone. 
The  displacement  of  the  fragments  depends  upon  the 
direction  and  degree  of  the  force  employed,  no 
muscles  having  effect.  The  bone  being  very  vascular, 
serious  injuries,  involving  great  loss  of  substance,  are 
often  wonderfully  repaired.  Its  hollowness,  and  the 
cavities  that  it  helps  to  bound,  render  it  possible 
for  large  foreign  bodies  to  be  retained  in  the 
deeper  parts  of  the  face.  Thus,  Longmore  reports 
"  the  case  of  Lieutenant  Fretz,  of  the  Ceylon  Rifles, 
who  was  able  to  do  his  military  duties  for  nearly 


no  SURGICAL  APPLIED  ANATOMY.     [Chap.  vu. 

eight  years,  with  the  breech  and  screw  of  a  burst 
musket  lodged  in  the  nares,  part  of  the  tail-pin  and 
screw  protruding  through  the  hard  palate  into  the 
mouth."  The  bone  may  undergo  extensive  necrosis, 
especially  in  that  form  of  necrosis  induced  in  workers 
in  match  factories  by  exposure  to  the  fumes  of  phos- 
phorus. In  one  case  (Med.  Times,  1862)  of  necrosis 
following  measles  the  mischief  was  limited  to  the  pre- 
maxillary,  or  incisive  bone. 

The  periosteum  of  the  superior  maxilla  is,  like  the 
pericranium,  not  disposed  to  form  new  bone.  In 
ordinary  cases  of  necrosis  of  the  upper  jaw  no  repro- 
duction of  bone  takes  place,  the  gap.  left  being  perma- 
nent. In  the  lower  jaw  abundant  new  bone  is  produced 
by  the  periosteum,  and  extensive  losses  maybe  repaired. 
It  is  vemarkable,  however,  that  in  course  of  years  this 
new  bone  is  liable  to  be  very  extensively  reabsorbed. 

Excision  of  the  superior  maxilla,  —  The 
entire  bone  has  been  frequently  removed  when  the 
seat  of  an  extensive  tumour,  and  under  certain  other 
conditions.  The  bony  connections  to  be  divided  in  the 
operation  are  the  following:  (1)  The  connection  with 
the  malar  bone  at  the  outer  side  of  the  orbit ;  (2)  the 
connection  of  the  nasal  process  with  the  frontal,  nasal, 
and  lachrymal  bones  ;  (3)  the  connections  of  the  orbital 
plate  with  the  ethmoid  and  palate  (this  plate  is  often 
left  behind,  or  is  cut  through  near  the  orbital  margin) ; 
(4)  the  connection  with  the  opposite  bone  and  the 
palate  in  the  roof  of  the  mouth  ;  and  (5)  the  connection 
behind  with  the  palate  bone,  and  the  fibrous  attach- 
ments to  the  pterygoid  processes.  In  the  four  first- 
named  instances  the  separation  is  effected  by  a  cutting 
instrument ;  in  the  last-named,  by  simply  twisting  out 
the  bone.  Soft  parts  divided :  These  may  be  con- 
sidered under  three  heads :  (1)  The  parts  cut  in  the  first 
incision  ;  (2)  in  turning  back  the  flap ;  and  (3)  in  sepa- 
rating the  bone. 


Chap.  VIM  THE  FACE.  in 

(1)  The  following  are  the  parts  cut  in  order  from 
above  downwards  in  the  usual,  or  "  median,"  incision, 
an  incision  commencing  parallel  with  the  lower 
eyelid,  and  continued  down  the  side  of  the  nose, 
round  the  ala,  and  through  the  middle  of  the  upper 
lip  :  Skin,  superficial  fascia,  orbicularis  palpebrarum, 
palpebral  branches  of  infraorbital  nerve  and  artery, 
part  of  lev.  labii  superioris,  angular  artery  and  vein, 
lev.  labii  sup.  alaeque  nasi,  lateralis  nasi  artery  and 
vein,  nasal  branches  of  infraorbital  nerve,  compressor 
naris,  depressor  alae  nasi,  attachment  of  nasal  carti- 
lage to  bone,  orbicularis  oris,  sup.  coronary  artery 
and  vein,  and  mucous  membrane  of  lip.  Various 
branches  of  the  facial  nerve  to  the  muscles  may  be 
cut.  (2)  In  turning  back  the  flap,  the  muscles  above 
named  will  be  dissected  up,  together  with  the  tendo 
oculi,  if  the  nasal  process  is  removed  entire,  the 
levator  anguli,  the  buccinator,  a  few  fibres  of  the 
masseter,  and,  on  the  orbital  plate,  the  inferior  ob- 
lique muscle.  The  infraorbital  nerve  and  artery 
will  be  cut  as  they  leave  their  foramen.  In  the  flap 
itself  will  be  the  trunks  of  the  facial  artery  and  vein, 
the  transverse  facial  artery,  and  the  facial  part  of  the 
facial  nerve.  (3)  In  separating  the  nasal  process,  the 
lachrymal  sac  and  infratrochlear  nerve  will  be  damaged, 
and  the  nasal  duct  and  external  branch  of  the  nasal 
nerve  cut  across.  In  separating  the  bones  below, 
the  coverings  of  the  hard  palate  are  divided,  and  the 
attachment  of  the  soft  palate  to  the  palate  bone, 
unless  the  removal  of  that  process  can  be  avoided. 
u  Any  attempt  to  dissect  off  and  preserve  the  soft 
covering  of  the  hard  palate  is  futile"  (Heath). 
Posteriorly,  the  trunk  of  the  infraorbital  nerve  is 
again  divided  (this  time  in  front  of  Meckel's  ganglion), 
together  with  the  posterior  dental  and  infraorbital 
arteries,  and  some  branches  of  the  spheno-palatine 
artery.  The  deep  facial  vein  from  the  pterygoid 


ii2  SURGICAL  APPLIED  ANATOMY,    ichap.  vn. 

plexus  will  probably  be  cut,  and,  lastly,  near  the 
palate  will  also  be  divided  the  large  palatine  nerve 
and  the  descending  palatine  artery. 

It  will  be  seen  that  no  large  artery  is  divided  in 
the  operation.  The  inferior  turbinated  bone  comes 
away,  of  course,  with  the  maxilla. 

The  inferior  maxilla;  fracture. — This  bone 
is  to  a  great  extent  protected  from  fracture  by  its  horse- 
shoe shape,  which  gives  it  some  of  the  properties  of  a 
spring,  by  its  density  of  structure,  by  its  great 
mobility,  and  by  the  buffer-like  interarticular  carti- 
lages that  protect  its  attached  extremities.  The  bone 
is  usually  broken  by  direct  violence,  and  the  fracture 
may  be  in  any  part.  The  symphysis  is  rarely  broken, 
on  account  of  its  great  thickness.  The  ramus  is  pro- 
tected by  the  muscular  pads  that  envelop  its  two 
sides,  and  the  coronoid  process  is  still  more  out  of  the 
risk  of  injury,  owing  to  the  depth  at  which  it  is 
placed  and  the  protection  it  derives  from  the  zygoma. 
The  weakest  part  of  the  bone  is  in  front,  where  its 
strength  is  diminished  by  the  mental  foramen,  and  by 
the  large  socket  required  for  the  canine  tooth.  It  is 
about  this  part,  therefore,  that  fracture  is  the  most 
common.  The  bone  may  be  broken  near,  or  even 
through,  the  symphysis  by  indirect  violence,  as  by  a 
blow  or  crushing  force  that  tends  to  approximate  the 
two  rami.  Thus,  the  jaw  has  been  broken  near  the 
middle  line  by  a  blow  in  the  masseteric  region.  The 
amount  of  displacement  in  fractures  of  this  bone  varies 
greatly,  and  is  much  influenced  by  the  nature  and 
direction  of  the  force.  In  general  terms,  it  may  be 
said  that,  when  the  body  of  the  bone  is  broken,  the 
anterior  fragment  is  drawn  backwards  and  downwards 
by  the  jaw  depressors,  the  digastric,  mylo-hyoid, 
genio-hyoid,  and  genio-hyo-glossus ;  while  the  hinder 
fragment  is  drawn  up  by  the  elevators  of  the  jaw, 
the  masseter,  int.  pterygoid,  and  temporal.  It  must 


Chap,  vii.]  THE  FACE.  113 

be  remembered  that  the  mylo-hyoid  muscle  will  be 
attached  to  both  fragments,  and  will  modify  the 
amount  of  displacement.  Fractures  of  the  ramus 
ai-e  seldom  attended  with  much  displacement,  muscular 
tissue  being  nearly  equally  attached  to  both  fragments. 

In  fractures  of  the  body  of  the  bone,  the  dental 
nerve  often  marvellously  escapes  injury,  a  fact  that  is 
explained  by  the  supposition  that  the  bones  are  not 
usually  sufficiently  displaced  to  tear  across  the  nerve. 
Weeks  after  the  accident,  however,  the  nerve  has 
become  so  compressed  by  the  developing  callus  as  to 
have  its  function  destroyed. 

One,  or  both,  condyles  have  often  been  broken  by 
falls  or  blows  upon  the  chin.  The  gums  being  firm 
and  adherent,  it  follows  that  they  are  usually  torn  in 
fractures  of  the  body  of  the  maxilla,  and  hence  the 
bulk  of  the  fractures  in  this  part  are  compound. 

The  tcmporo-maxillary  articulation  is 
supported  by  a  capsule  which  varies  greatly  in  thick- 
ness in  different  parts.  By  far  the  thickest  part  of 
the  capsule  is  the  external  part  (the  external  lateral 
ligament).  The  internal  part  is  next  in  thickness, 
while  the  anterior  and  posterior  portions  of  the  capsule 
are  thin,  especially  the  former,  which  is  very  thin. 
Thus,  when  this  joint  suppurates,  the  pus  is  least 
likely  to  escape  on  the  external  aspect  of  the  articula- 
tion, and  is  most  likely  to  find  an  exit  through  the 
anterior  part  of  the  capsule,  although  this  part  is  to  a 
great  extent  protected  by  the  attachments  of  the  ex- 
ternal pterygoid  muscle.  Immediately  behind  the  con- 
dyle  of  the  jaw  are  the  bony  meatus,  and,  a  little  to  the 
inner  side,  the  middle  ear.  In  violent  blows  upon  the 
front  of  the  jaw,  these  structures  may  be  damaged,  and 
it  is  interesting  to  note  that  the  strongest  ligament  of 
the  joint  (the  external  lateral)  has  a  direction  down- 
wards and  backwards,  so  as  to  immediately  resist  any 
movement  of  the  condyle  towards  the  slender  wall  of 


ii4  SURGICAL  APPLIED  ANATOMY.    [Chap,  vn 

bone  that,  bounds  the  meatus  and  tympanum.  Were  it 
not  for  this  ligament,  a  blow  upon  the  chin  would  be 
a  much  more  serious  accident  than  it  is  at  present. 

It  follows,  from  the  proximity  of  the  joint  to  the 
middle  ear,  that  disease  in  the  articulation  may  be  set 
up  by  suppuration  in  this  part.  In  one  case  (Holmes' 
"  System  of  Surgery  "),  suppurative  disease,  spreading 
from  the  middle  ear,  not  only  involved  the  joint,  but 
induced  necrosis  of  the  condyle  of  the  lower  jaw.  The 
necrosed  condyle  was  removed  entire  from  the  auditory 
meatus,  into  which  cavity  it  had  projected. 

Dislocation. — This  joint  permits  only  of  one 
form  of  dislocation,  a  dislocation  forwards.  It  may 
be  unilateral  or  bilateral,  the  latter  being  the  more 
usual,  and  it  can  only  occur  when  the  mouth  happens 
to  be  wide  open.  Indeed,  the  dislocation  is  nearly 
always  due  to  spasmodic  muscular  action  when  the 
mouth  is  open,  although  in  some  few  cases  it  has  been 
brought  about  by  indirect  violence,  as  by  a  downward 
blow  upon  the  lower  front  teeth,  the  mouth  being 
widely  opened.  It  has  occurred  during  yawning, 
violent  vomiting,  etc.  In  more  than  one  case  the 
accident  happened  while  a  dentist  was  taking  a  cast 
of  the  mouth.  Hamilton  quotes  a  bilateral  dislocation 
in  a  woman  during  the  violent  gesticulations  incident 
to  the  pursuit  of  scolding  her  husband.  When  the 
mouth  is  widely  opened,  the  condyles,  together  with 
the  interarticular  nbro-cartilage,  glide  forwards.  The 
fibre-cartilage  extends  as  far  as  the  anterior  edge  of  the 
eminentia  articularis,  which  is  coated  with  cartilage 
to  receive  it.  The  condyle  never  reaches  quite  so  far  as 
the  summit  of  that  eminence.  All  parts  of  the  capsule 
save  the  anterior  are  rendered  tense.  The  coronoid 
process  is  much  depressed.  Now  if  the  external 
pterygoid  muscle  (the  muscle  mainly  answerable  for 
the  luxation)  contract  vigorously,  the  condyle  is  soon 
drawn  over  the  eminence  into  the  zygomatic  fossa,  the 


Chap,  vii.]  THE  FACE.  115 

interarticular  cartilage  remaining  behind.  On  reaching 
its  new  position  it  is  immediately  drawn  up  by  the 
temporal,  internal  pterygoid,  and  masseter  muscles,  and 
is  thereby  more  or  less  fixed.  A  specimen  in  the 
Musee  Dupuytren  shows  that  the  fixity  of  the  luxated 
jaw  may  sometimes  depend  upon  the  catching  of  the 
apex  of  the  coronoid  process  against  the  malar  bone. 

Subliixation  of  the  jaw  is  a  name  given  to  a 
slight  and  quite  incomplete  dislocation  of  the  jaw,  not 
infrequently  met  with  in  delicate  women.  It  is  due 
to  a  displacement  of  the  interarticular  cartilage,  and 
can  be  cured  by  exposing  the  cartilage  and  attaching 
it  by  suture  to  the  fibrous  structures  around  the  joint 
(Annandale). 

Excision  of  the  inferior  maxilla.— Con- 
siderable portions  of  the  lower  jaw  can  be  excised 
through  the  mouth  without  external  wound.  In 
excising  one  entire  half  of  the  maxilla  a  cut  is  made 
vertically  through  the  lower  lip  down  to  the  point  of 
the  chin,  and  is  then  continued  back  along  the  inferior 
border  of  the  jaw,  so  as  to  end  near  the  lobule  of 
the  ear,  after  having  been  carried  vertically  upwards 
in  the  line  of  the  posterior  border  of  the  ramus.  The 
soft  parts  divided  may  be  considered  under  three 
heads  :  (1)  Those  concerned  in  the  first  incision  ;  (2) 
in  clearing  the  outer  surface  of  the  bone  ;  (3)  in 
clearing  the  inner  surface  of  the  bone. 

1.  (a)  In  the  anterior  vertical  cut:  Skin,  etc., 
orbicularis  oris,  inferior  coronary  and  inferior  labial 
vessels,  branches  of  submental  artery,  levator  menti. 
mental  vessels  and  nerve,  some  radicles  of  anterior 
jugular  vein,  (b)  In  the  horizontal  cut :  Skin,  etc.,  pla- 
tysma,  branches  of  superficial  cervical  nerve,  branches 
of  supramaxillary  part  of  facial  nerve,  facial  artery  and 
vein  at  edge  of  masseter,  and  inframaxillary  branch 
of  facial  nerve  (not  necessarily  divided),  (c)  The  pos- 
terior vertical  incision  would  not  go  down  to  the  bone, 


n6  SURGICAL  APPLIED  ANATOMY.    [Chap.  vi:. 

and  would  merely  expose  the  surface  of  the  parotid 
gland,  and  part  of  posterior  border  of  masseter  muscle. 

2.  In    clearing   the   outer   surface   the   following 
parts   are   dissected  back :  Levator   menti,  the   two 
depressor   muscles,  buccinator,   masseter  (crossed  by 
part  of  parotid  gland,  transverse  facial  vessels,  facial 
nerve  and  Stenson's  duct),  masseteric  vessels  and  nerve, 
temporal  muscle. 

3.  In  clearing  the  inner  surface  :  Digastric,  genio- 
hyoid,  genio-hyo-glossus,   and    mylo-hyoid  muscles,  a 
few  fibres  of  superior  constrictor,  internal  pterygoid 
muscle,  inferior  dental  artery  and  nerve,  mylo-hyoid 
vessels  and  nerve,  internal  lateral   ligament,  rest   of 
insertion  of  temporal  muscle,  mucous  membrane. 

Parts  in  risk  of  being  damaged. — The  facial  nerve, 
if  the  posterior  vertical  incision  be  carried  too  high  up. 
The  internal  maxillary  artery,  temporo-maxillary  vein, 
auriculo-temporal  nerve  (structures  all  closely  related 
to  the  jaw  condyle),  external  carotid  artery,  lingual 
nerve,  the  parotid,  submaxillary,and  sublingual  glands. 
After  subperiosteal  resection  the  entire  bone  has  been 
reproduced. 

Deformities. — The  lower  jaw  may  be  entirely 
absent,  or  may  be  of  dwarfed  dimensions,  or  be  incom- 
pletely formed.  These  conditions  are  congenital,  and 
depend  upon  defective  development  of  the  maxillary 
part  of  the  first  branchial  arch.  They  are  often 
associated  with  branchial  fistulse,  supernumerary  ears, 
macrostoma,  and  like  congenital  malformations. 

With  regard  to  the  nerves  connected  with  the 
jaws  little  need  be  said.  The  upper  teeth  are  supplied 
by  the  second  division  of  the  fifth,  the  lower  by  the 
third.  Some  remarkable  nerve  disturbances  have 
followed,  by  reflex  action,  upon  irritation  of  the 
dental  nerves.  Thus  cases  of  strabismus,  temporary 
blindness,  and  wry-nock  have  been  reported  as  due 
to  the  irritation  of  carious  teeth.  Hilton  gives 


Cha,..  vii.]  Til E  FACE.  117 

the  case  of  a  man  who  was  much  troubled  by  a 
carious  tooth  in  the  lower  jaw  (supplied  by  the  third 
division  of  the  fifth),  and  who  developed  a  patch  of 
grey  hair  over  the  region  supplied  by  the  auriculo- 
temporal  nerve  (a  branch  also  of  the  third  division). 

The  muscles  of  mastication  are  often  attacked 
by  spasm.  When  the  spasm  is  clonic  the  chattering 
of  the  teeth  is  produced  that  is  so  conspicuous  a 
feature  in  rigor.  When  the  spasm  is  tonic  the  mouth 
is  rigidly  closed,  and  the  condition  known  as  trisnius, 
or  lockjaw,  is  produced.  Trismus  is  among  the  tirst 
symptoms  of  tetanus.  It  is  also  very  apt  to  be  pro- 
duced by  irritation  of  any  of  the  sensory  branches 
of  the  third  division  of  the  fifth,  since  the  motor  nerve 
supply  of  the  muscles  themselves  is  derived  from  that 
trunk.  Thus  trismus  is  very  common  in  caries  of  the 
lower  teeth,  and  during  the  "cutting"  of  the  lower 
wisdom  tooth.  It  is  much  less  common  in  affections 
of  the  upper  set  of  teeth,  since  they  are  supplied  by 
a  more  remote  division  of  the  fifth  nerve. 

Teeth. — As  a  test  of  age  the  following  periods 
for  the  eruption  of  teeth  are  given  by  Mr.  C.  Tomes  : 
Temporary  teeth  :  Lower  central  incisors,  six  to  nine 
months ;  upper  incisors,  ten  months ;  lower  lateral 
incisors,  and  four  first  molars,  a  few  months  later  ; 
then,  after  a  rest  of  four  or  five  months,  the  canines  ; 
and,  lastly,  the  second  molars ;  the  whole  being  in  place 
by  the  end  of  the  second  year.  Permanent  teeth  :  First 
molars,  sixth  or  seventh  year ;  next  in  order  the 
lower  central  incisors,  then  the  upper  central  incisors, 
and  a  little  later  the  laterals,  the  eighth  year ;  first, 
bicuspids,  ninth  or  tenth  year ;  second  bicuspids  and 
canines,  about  the  eleventh  year,  the  lower  preceding 
the  upper ;  the  second  molars,  the  twelfth  or  thirteenth 
year ;  the  wisdom  teeth,  eighteen  to  twenty-five  or  later. 

An  alveolar  abscess  is  an  abscess  about  the 
fang  of  a  tooth.  In  the  case  of  single-fanged  teeth 


ti8  SURGICAL  APPLIED  ANATOMY.     [i:iv.p.  vm. 

the  pus  may  escape  along  the  groove  of  the  fang. 
With  other  teeth  the  pus  tends  to  pierce  the  alveolus, 
If  the  point  of  the  fang  is  within  the  reflection  of  the 
mucous  membrane  from  the  gum  to  the  cheek  the 
abscess  will  break  into  the  mouth,  but  if  the  point  of 
the  fang  is  without  that  reflection,  or  if  the  pus  can 
gravitate  without  the  line  of  the  reflection,  then  the 
pus  may  break  through  the  cheek.  Alveolar  abscess 
of  the  upper  incisors  and  canines  never  breaks  through 
the  cheek.  When  connected  with  the  upper  molars  it 
sometimes  does.  When  connected  with  any  of  the 
lower  teeth  the  abscess  may  find  its  way  through  the 
skin  of  the  cheek. 


CHAPTER  VIII. 

THE    MOUTH,    TONGUE,    PALATE,    AND    PHARYNX. 

THE  lips. — The  principal  tissues  composing  the 
lips  have  the  following  relation  to  one  another  pro- 
ceeding from  without  inwards:  (1)  Skin;  (2)  super- 
ficial fascia;  (3)  orbicularis  oris  ;  (4)  coronary  vessels; 
(5)  mucous  glands ;  and  (6)  mucous  membrane.  The 
free  border  of  the  lip  is  very  sensitive,  many  of  the 
nerves  having  end  bulbs  closely  resembling  tactile 
corpuscles.  The  upper  lip  is  supplied  with  sensation 
by  the  second  division  of  the  fifth  nerve,  and  the  lower 
lip  by  the  third  division.  Over  these  labial  nerves  a 
crop  of  herpes  often  appears  (herpes  labialis).  The 
free  border  of  the  lower  lip  is  more  frequently  the  seat 
of  epithelioina  than  is  any  other  part  of  the  body. 
The  lips  contain  a  good  deal  of  connective  tissue,  and 
may  swell  to  a  considerable  size  when  inflamed,  or 
cedematous.  They  are  very  mobile,  and  are  entirely 
free  for  a  considerable  extent  from  bony  attachment 
of  any  kind.  It  follows  that  destructive  inflamma- 
mutions  of  the  lips,  and  such  losses  of  substance  as 
accompany  severe  burns,  produce  much  contraction 


Chap,  vni.]  THE  MOUTH.  i«) 

and  deformity  of  the  mouth.  Contracting  cicatrices, 
also,  in  the  vicinity  of  the  mouth  are  apt  to  drag  upon 
the  lips,  everting  them,  or  producing  kindred  distor- 
tions. It  is  fortunate  that  the  laxity  of  the  tissues 
around  the  mouth,  and  the  general  vascularity  of  the 
part,  greatly  favour  the  success  of  the  many  plastic 
operations  performed  to  relieve  these  deformities. 

The  lips  are  very  vascular,  and  are  often  the  seat 
of  nsevi  and  other  vascular  tumours.  The  coronary 
arteries  are  of  large  size,  and  their  pulsations  can 
generally  be  felt  when  the  lip  is  pinched  up.  These 
vessels  run  beneath  the  orbicularis  oris  muscle,  and 
are  consequently  nearer  to  the  mucous  membrane  than 
they  are  to  the  skin.  When  the  inner  surface  of  the 
lip  is  cut  against  the  teeth,  as  the  result  of  a  blow, 
these  arteries  are  very  apt  to  be  wounded.  As 
such  wounds  are  concealed  from  view,  the  consequent 
haemorrhage  has  sometimes  given  rise  to  an  erroneous 
diagnosis.  Thus,  Mr.  Erichsen  quotes  the  case  of  a 
drunken  man,  the  subject  of  such  a  wound,  who, 
having  swallowed,  and  then  vomited,  the  blood  escap- 
ing from  a  coronary  artery,  was  for  awhile  supposed 
to  be  suffering  from  an  internal  injury.  As  the  anas- 
tomoses between  the  arteries  of  the  lip  ai'e  very  free, 
it  is  usually  necessary  to  tie  both  ends  of  the  vessel 
when  it  lias  been  cut  across. 

The  mucous  glands  in  the  submucous  tissue  are  large 
and  numerous.  From  closure  of  the  ducts  of  these 
glands,  and  their  subsequent  distension,  result  the 
"  mucous  cysts  "  that  are  so  common  about  the  lips. 
It  has  been  shown  (Holmes'  "  System  of  Surgery," 
voL  ii.)  that  one  form  of  enlarged  lip  may  depend 
upon  a  general  hypertrophy  of  these  glands  in  the 
submucous  tissue.  "  Hare-lip "  is  noticed  below  in 
connection  with  the  subject  of  cleft  palate. 

The  buccal  cavity.— The  following  points  may 
be  noticed  in  the  examination  of  the  interior  of  the 


120  SURGICAL  APPLIED  A.VATO.VY.  [Ch:,p.  vm. 

mouth.  On  the  floor  of  the  mouth,  and  on  either  side 
of  the  franium  linguae,  can  be  observed  a  small  papilla 
indicating  the  orifice  of  Wharton's  duct.  The  duct  of 
Bartholin  (one  of  the  ducts  of  the  sublingual  gland) 
runs  along  the  last  part  of  Wharton's  duct,  and  opens 
either  with  it  or  very  near  it.  Wharton's  duct  is 
singularly  indistensible,  and  hence  is  partly  explained 
the  intense  pain  usually  observed  when  that  duct 
is  obstructed  by  a  calculus.  The  near  proximity  of 
this  duct  to  the  lingual  nerve  may  serve  also  to 
account  for  the  pain  in  some  cases.  The  submaxillary 
gland  can  be  made  out  through  the  mucous  membrane 
at  a  point  a  little  in  front  of  the  angle  of  the  jaw, 
especially  when  the  gland  is  pressed  up  from  the 
outside.  On  the  floor  of  the  mouth,  between  the 
alveolus  and  the  anterior  part  of  the  tongue,  is  a 
well-marked  ridge  of  mucous  membrane,  that  is 
directed  obliquely  forwards  and  inwards  to  the 
Whartonian  papilla  near  the  frsenum.  It  indicates 
the  position  of  the  sublingual  gland,  and  also,  so  far 
as  it  goes,  the  line  of  Wharton's  duct  and  the  lingual 
nerve.  These  structures  lie  beneath  the  gland,  which 
is  itself  covered  only  by  the  mucous  membrane. 
The  ducts  of  the  sublingual  gland,  some  ten  to 
twenty  in  number,  open  into  the  mouth  along  the 
ridge  of  mucous  membrane  just  referred  to.  Ranula, 
a  cystic  tumour  filled  with  mucous  contents,  is  often 
met  with  over  the  site  of  the  sublingual  gland,  and 
is  due  to  the  dilatation  of  one  of  the  gland  ducts 
that  has  become  obstructed,  or  to  an  occluded  mucous 
follicle.  The  mucous  membrane  of  the  floor  of  the 
mouth,  as  it  passes  forwards  to  be  reflected  on  the 
gums,  is  attached  near  to  the  upper  border  of  the 
jaw.  The  genio-hyo-glossus  is  attached  near  the 
lower  border.  Between  these  two  parts  (the  mucous 
membrane  and  the  muscle)  there  is,  according  to 
Tillaux,  a  small  space  lined  with  squamous  epithelium. 


Chap,  vin.]  THE  MOUTH.  121 

To  this  cavity  the  name  is  given  of  the  sublingual 
bursa  mucosa.  It  is  constricted  in  its  centre  by  the 
framum  linguae,  and  is  said  to  be  the  seat  of  mischief 
in  "  acute  ranula." 

When  the  mouth  is  widely  opened  the  pterygo- 
maxillary  ligament  can  be  readily  seen  and  felt 
beneath  the  mucous  membrane.  It  appeal's  as  a 
prominent  fold  running  obliquely  downwards  behind 
the  last  molar  teeth.  A  little  below  and  in  front  of 
the  attachment  of  this  ligament  to  the  lower  jaw,  the 
gustatory  nerve  can  be  felt  as  it  lies  close  to  the  bone 
just  below  the  last  molar.  This  nerve  is  sometimes 
divided  for  the  relief  of  pain  in  cases  of  carcinoma 
of  the  tongue.  Mr.  Moore's  method  of  dividing  it  is 
as  follows :  "  He  cuts  the  nerve  about  half  an  inch 
from  the  last  molar  tooth,  at  a  point  where  it  crosses 
an  imaginary  line  drawn  from  that  tooth  to  the  angle 
of  the  jaw.  He  enters  the  point  of  the  knife  nearly 
three-quarters  of  an  inch  behind  and  below  the  tooth, 
presses  it  down  to  the  bone,  and  cuts  towards  the 
tooth"  (Stimson).  This  nerve,  as  it  lies  against  the 
bone,  has  been  crushed  by  the  slipping  of  the  forceps 
in  the  clumsy  extraction  of  the  lower  molar  teeth. 

The  coronoid  process  of  the  lower  jaw  can  be 
easily  felt  through  the  mouth,  and  is  especially  distinct 
when  that  bone  is  dislocated.  It  may  be  noted  that 
a  fair  space  exists  between  the  last  molar  tooth  and 
the  ramus  of  the  inferior  maxilla,  through  which  a 
patient  may  be  fed  by  a  tube  in  cases  of  trismus  or 
anchylosis  of  the  jaw. 

A  congenital  dermoid  cyst  is  sometimes  found  in 
the  floor  of  the  mouth  between  the  tongue  and  the 
lower  jaw.  Such  cysts  have  been  supposed  to  be  due 
to  the  imperfect  closure  of  the  first  branchial  cleft,  the 
cleft  immediately  behind  the  first  branchial  arch, 
about  which  the  lower  jaw  is  developed. 

The  gums  are  dense,  firm,  and  very  vascular.     In 


122  SUKGICAL    APPLIED   ANATOMY.     [Chap.  VIII. 

the  bleeding  that  follows  the  extraction  of  teeth  much 
of  the  blood  is  supplied  by  them.  The  gums  are 
particularly  affected  in  mercurial  poisoning,  and  are 
also  especially  involved  in  scurvy.  In  chronic  lead- 
poisoning  a  blue  line  often  appears  along  their  margins. 
This  is  due  to  a  deposit  of  lead  sulphide  in  the  gum 
tissues,  which  is  thus  derived  :  Food  debris  collected 
about  the  teeth  in  decomposing  produces  hydrogen 
sulphide,  which,  acting  upon  the  lead  circulating  in  the 
blood,  produces  the  deposit.  The  blue  line,  therefore, 
is  said  not  to  occur  in  those  who  keep  the  teeth  clean. 

The  tongue.— On  the  under  surface  of  the  tongue, 
less  than  half  an  inch  from  the  fraenum,  the  end  of  the 
ranine  vein  can  be  seen  beneath  the  mucous  membrane. 
Two  elevated  and  fringed  lines  of  mucous  membrane 
may  be  seen  on  the  under  surface  of  the  organ 
converging  towards  its  tip.  They  indicate  the  position 
of  the  ranine  artery,  which  is  more  deeply  placed  than 
the  vein,  close  to  which  it  lies.  It  is  extremely  rare 
for  the  tongue  to  be  the  seat  of  congenital  defect.  The 
author  of  the  able  monograph  on  the  tongue  in 
Holmes'  "  System  of  Surgery  "  has  discovered  only 
one  instance  of  congenital  absence  of  the  organ. 
Fournier  gives  a  case  where  the  tongue  was  so  much 
longer  than  usual  that  the  chest  could  be  touched 
with  its  tip  while  the  head  was  held  erect. 

In  rare  cases  the  fraeimm  lingua;  may  be 
abnormally  short,  constituting  the  condition  known 
as  "  tongue-tie,"  which  is  really  a  very  uncommon 
affection.  The  frsenum  when  divided  should  be  cut  as 
near  the  jaw  as  possible,  so  as  to  avoid  the  ranine 
vessels.  Division  of  these  vessels  in  relieving  tongue- 
tie  has  led  to  fatal  haemorrhage,  the  bleeding  being 
encouraged  by  the  efforts  of  sucking.  "  If  the  frsenum 
and  subjacent  muscle  fibres  be  too  freely  divided, 
energetic  sucking  on  the  part  of  a  hungry  child  may 
tear  the  wound  of  these  very  lax  tissues  farther  and 


chap,  viii.]  THE  TONGUE.  123 

farther  open,  until  the  tongue,  having  lost  all  its 
anterior  support,  turns  over  into  the  pharynx,  and  is 
firmly  embraced  by  the  muscles  of  deglutition,  which 
force  it  down  upon  the  epiglottis,  and  the  latter  upon 
the  larynx,  until  suffocation  is  produced "  (Holmes' 
"System  of  Surgery,"  vol.  ii.).  In  complete  anaesthesia, 
as  in  that  produced  by  chloroform,  when  all  the 
muscular  attachments  of  the  tongue  are  relaxed,  the 
organ  is  apt  to  fall  back  and  to  press  down  the  epi- 
glottis, so  causing  suffocation. 

The  tongue  is  firm  and  dense,  but  contains,  never- 
theless, a  sufficient  amount  of  connective  tissue  to 
cause  it  to  swell  greatly  when  inflamed.  Foreign 
bodies  may  easily  be  embedded  in  its  substance.  In 
the  Lancet  for  1846  is  noted  a  case  where  a  portion 
of  a  fork  is  said  to  have  been  buried  in  the  tongue  for 
thirty-two  years.  The  surface  epithelium  is  thick, 
and  in  chronic  superficial  inflammation  of  the  organ 
it  often  becomes  heaped  up,  forming  dense  opaque 
layers,  ichthyosis  linguae,  plaques  des  fumeurs, 
leucoma,  etc.  From  the  mucous  glands,  situated 
chiefly  beneath  the  mucous  membrane  near  the  base 
of  the  tongue,  the  mucous  cysts  are  developed  that  are 
sometimes  met  with  in  this  part. 

The  tongue  is  very  vascular,  and  is  in  consequence 
often  the  seat  of  naevoid  growths.  Its  main  supply  is 
from  the  lingual  artery.  This  vessel  approaches  the 
organ  from  the  under  surface,  and  as  cancer  usually 
shows  a  tendency  to  spread  towards  the  best  blood 
supply,  it  is  to  be'  noticed  that  carcinoma  of  the  tongue 
nearly  always  tends  to  spread  towards  the  deep  attach- 
ment of  the  member.  At  the  same  time  it  must  be 
observed  that  the  main  lymphatics  follow  the  same 
course  as  the  main  blood-vessels.  The  vascularity 
of  the  tongue  is  the  great  bar  to  its  easy  removal, 
haemorrhage  being  the  complication  most  to  be  dreaded 
in  such  operations. 


124  SURGICAL  APPLIED  ANATOMY.    [Chap.  vin. 

The  tongue  is  well  supplied  with  nerves,  that  endue 
it  riot  only  with  the  special  sense  of  taste,  but  also 
with  caramon  sensation.  According  to  Weber's  ex- 
periments, tactile  sensibility  is  more  acute  on  the  tip 
of  the  tongue  than  it  is  on  any  other  part  of  the 
surface  of  the  body.  It  should  be  borne  in  mind  that 
the  lingual  nerve  supplies  the  forepart  and  sides  of 
the  tongue  for  two-thirds  of  its  surface,  while  the 
glosso-pharyngeal  nerve  supplies  the  mucous  mem- 
brane at  its  base,  and  especially  the  papillae  vallatse. 
In  painful  affections  of  the  tongue  in  the  district  sup- 
plied by  the  lingual  nerve,  the  patient  often  is  troubled 
with  severe  pain  deep  in  the  region  of  the  meatus  of 
the  ear.  The  pain  in  such  instances  is  referred  along 
the  course  of  the  third  division  of  the  fifth,  of  which 
trunk  the  lingual  nerve  is  a  branch.  In  like  manner 
spasmodic  contraction  of  the  masticatory  muscles  is 
sometimes  found  to  accompany  painful  lingual  ulcers 
when  involving  the  region  of  the  gustatory  nerve. 
There  would  seem  to  be  but  little  connection  between 
an  abscess  over  the  occipital  region  and  wasting  of  one 
half  of  the  tongue.  But  Sir  James  Paget  reports  the 
following  case  :  "  A  man  received  an  injury  to  the 
back  of  his  head  that  was  apparently  not  severe.  In 
time  the  right  half  of  the  tongue  began  to  waste,  and 
continued  to  waste  until  it  was  less  than  half  the  size 
of  the  unaltered  side.  An  abscess  formed  over  the 
occiput,  from  which  fragments  of  the  lower  part  of 
the  occipital  bone  were  removed.  After  the  removal  of 
all  the  dead  bone  the  tongue  began  to  recover,  and  in 
one  month  had  nearly  regained  its  normal  aspect." 
Here  the  atrophy  was  due  to  wasting  of  the  lingual 
muscles  produced  by  pressure  upon  the  hypoglossal 
nerve,  which  leaves  the  skull  through  the  anterior 
condyloid  foramen  in  the  occipital  bone.  The  case 
illustrates  the  importance  of  remembering  even  small 
fjiMiniu.1,  and  the  structures  they  transmit 


Chap,  vni.)  THE  TONGUE.  125 

The  tongue  contains  much  lymphoid  tissue,  a 
considerable  part  of  which  is  massed  under  the 
mucous  membrane  at  the  posterior  part  of  the  organ. 
The  lymphatics  also  are  large  and  numerous,  and  for 
the  most  part  follow  the  ranine  vessels.  With  regard 
to  glandular  infection  in  lingual  cancer,  it  is  well  to 
note  that  these  lymphatics  enter  one  or  two  small 
glands  lying  on  the  hyo-glossus  muscle  before  they 
reach  the  deep  glands  in  the  neck,  where  they  finally 
end. 

In  the  strange  congenital  affection  known  as  macro- 
glossia  the  tongue  becomes  much  enlarged,  and  in  some 
cases  may  attain  prodigious  dimensions.  Thus,  in  one 
case  it  measured  six  and  a  half  inches  in  length  and 
ten  inches  in  circumference.  It  has  protruded  so  far 
from  the  mouth  as  to  reach  even  to  the  episternal 
notch.  It  has  been  so  large  as  to  deform  the  teeth 
and  alveolus,  and  in  one  case  dislocated  the  jaw. 
The  enlargement  is  primarily  due  to  the  greatly 
dilated  condition  of  the  lymphatic  channels  of  the 
organ  (hence  the  name,  lymphangioma  cavernosum, 
proposed  by  Virchow),  and  to  an  increased  develop- 
ment of  lymph  tissue  throughout  the  part.  The 
portion  most  conspicuously  affected  is  the  base  of  the 
tongue,  where  the  lymphatics  are  usually  the  most 
numerous. 

A  dermoid  cyst  may  be  met  with  on  the  under 
surface  of  the  tongue.  It  is  usually  placed  in  the 
median  line  between  the  genio-hyo-glossi  muscles. 
Such  cysts  are  probably  due  to  some  infolding  of  the 
integumental  layer  during  development. 

Accessory  glands  about  the  tongue.— 
Streckeisen  states  that  accessory  glands,  belonging  to 
the  thyroid  body,  are  frequently  found  in  the  vicinity 
of  the  hyoid  bone.  Some  may  be  superficial  to  the 
mylo-hyoid  muscle,  others  may  be  just  above  the  hyoid 
bone,  and  others  in  the  hollow  of  that  bone.  Cysts 


iz6  SURGICAL  APPLIED  ANATOMY.   [Chap.  vin. 

lined  with  ciliated  epithelium  may  sometimes  be  found 
in  the  same  situations.  All  these  structures  are  the 
remains  of  the  neck  of  the  central  diverticulum  which 
is  protruded  from  the  ventral  wall  of  the  pharynx  in 
the  embryo,  and  from  which  the  chief  part  of  the 
thyroid  gland  is  formed.  The  foramen  caicum  on  the 
tongue  indicates  the  spot  where  this  diverticulum 
leaves  the  pharynx.  Ducts  lined  with  epithelium 
have  been  found  leading  from  the  foramen  caecum  to 
accessory  glands  about  the  hyoid  bone.  It  is  prob- 
ably from  these  glandular  and  epithelial  collections 
about  the  hyoid  bone  that  certain  deep-seated  forms 
of  cancer  of  the  neck  are  developed.  Some  of  these 
take  the  form  of  malignant  cysts  described  by  the 
author  (Path.  Soc.  Trans.,  1886). 

Much  adenoid  tissue  lies  at  the  back  of  the 
tongue  about  the  base  of  the  epiglottis.  The  hyper- 
trophy of  this  tonsil-like  tissue  (the  lingual  tonsil) 
may  lead  to  troublesome  symptoms  by  impairing  the 
movements  of  the  epiglottis. 

Excision. — Many  different  methods  have  been 
adopted  for  the  removal  of  the  entire  tongue.  It  has 
been  removed  through  the  mouth  by  the  ecraseur  or 
the  scissors,  the  latter  operation  being  performed  with 
or  without  previous  ligature  of  the  lingual  arteries  in 
the  neck.  It  is  difficult,  however,  to  fully  expose  the 
deeper  attachments  of  the  organ  through  the  compara- 
tively small  orifice  of  the  mouth.  To  obtain  more 
room  the  cheek  has  been  slit  up  in  one  procedure, 
while  the  lower  lip  and  symphysis  of  the  lower  jaw 
have  been  divided  in  another. 

In  another  series  of  operations  the  tongue  has 
been  reached,  or  the  organ  has  been  fully  exposed,  by 
an  incision  made  between  the  hyoid  bone  and  the 
inferior  maxilla.  More  recently  Kocher  has  exposed 
the  tongue  from  the  neck,  and  has  reached  it  by  an 
incision  commencing  near  the  ear  and  following  the 


Chip,  viii.j  THE  PALATE,  127 

anterior  border  of  the  sterno-mastoid  muscle  as  far  as 
the  liyoid  bone,  whence  it  turns  upwards  along  the 
anterior  belly  of  the  digastric  muscle. 

In  the  removal  of  the  entire  organ,  the  following 
parts  are  of  necessity  divided :  The  fraenum,  tho 
mucous  membrane  along  the  sides  of  the  tongue,  the 
glosso-epiglottic  folds,  the  genio-hyo-glossus,  hyo- 
glossus,  stylo-glossus,  palato-glossus  muscles,  the  few 
fibres  of  the  superior  and  inferior  linguales  muscles 
that  are  attached  to  the  hyoid  bone,  the  terminal 
branches  of  the  gustatory,  glosso-pharyngeal,  and  hypo- 
glossal  nerves,  the  lingual  vessels,  and,  at  the  side  of 
the  tongue  near  its  base,  some  branches  of  the  ascend- 
ing pharyngeal  arteiy,  and  of  the  tonsilar  branch  of 
the  facial  artery. 

Bleeding  from  the  stump  of  the  tongue,  after  re- 
moval, can  be  instantly  and  almost  entirely  arrested 
by  pressing  the  root  of  the  tongue  forwards  by  two 
fingers  passed  down  behind  it  into  the  pharynx.  The 
lingual  arteries  as  they  lie  divided  in  the  floor  of  the 
mouth  are  difficult  to  secure.  They  are  embedded  in 
muscle,  and  appear  to  be  peculiarly  brittle. 

When  both  linguals  have  been  ligatured  in  the 
neck  (through  the  hyo-glossus  muscle)  before  removing 
the  tongue,  bleeding  still  takes  place  from  the  dorsalis 
linguae  branches  of  the  lingual  and  from  small  bran- 
ches of  the  ascending  pharyngeal  and  facial  arteries. 

The  palate. — The  arch  of  the  hard  palate  varies 
in  height  and  shape  in  different  individuals,  and  it 
has  been  said  that  the  arch  is  particularly  narrow  and 
high  in  congenital  idiots.  The  outline  of  this  arch  is 
of  some  moment  in  operations  upon  the  palate. 

Cleft  palate. — The  palate  is  often  the  seat  of  a 
congenital  cleft.  The  cleft  is  precisely  in  the  middle 
line.  It  may  involve  the  uvula  or  the  soft  palate 
alone,  or  may  extend  forwards  and  involve  the  hard 
palate  as  far  as  the  alveolus.  If  it  extend  beyond  the 


ia8  SURGICAL  APPLIED  Ax  ATOMY,   tchap.  vin. 

alveolus,  the  cleft  will  leave  the  middle  line  and  will 
follow  the  suture  between  the  superior  maxillary  bone 
and  the  os  incisivum,  appearing  therefore  between  the 
incisor  and  canine  teeth.  Sometimes  at  the  end  of  the 
cleft  the  upper  lip  is  fissured  (hare-lip).  Hare-lip  is  ex- 
ceedingly rare  in  the  middle  line.  The  slit  usually  corre- 
sponds to  the  suture  just  named,  and  is  therefore  oppo- 
site the  interval  between  the  lateral  incisor  and  canine 
teeth.  Sometimes  the  cleft  in  the  palate  on  reaching  the 
alveolus  will  run  on  either  side  of  the  os  incisivum,  so 
that  that  bone  is  entirely  separated  from  the  superior 
maxilla.  Such  cases  are  associated  with  double  hare- 
lip, and  the  os  incisivum  appears  as  a  nodule  attached 
to  the  nose  and  suspended  in  the  centre  of  the  gap. 
The  bone  in  these  cases  contains,  as  a  rule,  the  germs 
only  of  the  central  incisors,  the  lateral  incisors  having 
been  lost  in  the  cleft.  Hai-e-lip  very  commonly  exists 
without  any  cleft  of  the  palate.  Except  in  very  rare 
instances,  a  cleft  of  the  hard  palate  will  not  exist  with- 
out a  cleft  of  the  soft.  In  some  cases  the  os  incisivum 
may  be  entirely  absent,  and  then  the  double  hare-lip 
that  exists  may  appear  as  a  large  median  gap  in  the 
lip.  When  the  hard  palate  is  entirely  cleft  the  edges 
of  the  cleft  are  more  or  less  perpendicular,  whereas 
when  the  cleft  is  very  slight  as  regards  its  antero-pos- 
terior  length,  the  palate  tends  to  preserve  more  or 
less  of  its  normal  curve. 

The  buccal  cavity,  when  first  formed  in  the  foetus, 
exists  as  a  wide  cleft  in  the  face  bounded  above  by  the 
fronto-nasal  process,  at  the  sides  by  the  superior  maxil- 
lary processes,  and  below  by  the  first  visceral  arch, 
around  which  the  lower  jaw  is  formed.  The  nasal 
and  buccal  cavities  are  one.  "  The  separation  of  the 
cavity  of  the  mouth,  strictly  so  called,  from  the  nasal 
fossae,  is  effected  by  the  development  of  the  palatal  or 
pterygo-palatal  processes  of  the  maxillary  plate,  which, 
advancing  inwards  from  the  two  sides,  meet  and 


Chap,  viiij  THE  PALATE.  129 

coalesce  with  each  other  and  with  the  septum  descend- 
ing from  above  in  the  middle  line.  .  .  .  When  the 
union  of  the  opposite  parts  takes  place,  the  naso- 
palatine  canal  is  left  as  the  vestige  of  the  previous 
fissures.  The  median  union  of  the  palate  begins  in 
front  about  the  eighth  week  in  the  human  embryo, 
and  reaches  the  back  part,  when  completed,  in  the 
ninth  and  tenth  weeks  "  (Allen  Thomson,  in  Quain's 
"  Anatomy  "). 

In  this  way  the  hard  and  soft  palates  are  formed, 
and  the  upper  lip  completed  ;  and  it  will  be  under- 
stood that  hare-lip  and  cleft  palate  depend  simply 
upon  imperfect  closure  of  the  foetal  gap  between  the 
nasal  and  buccal  cavities. 

The  mucous  membrane  covering  the  hard 
palate  is  peculiar  in  that  it  is  practically  one  with 
the  periosteum  covering  the  bones ;  and,  therefore,  in 
dissecting  up  this  membrane  the  bone  is  bared,  as  the 
mucous  membrane  and  the  periosteum  cannot  be 
separated.  The  membrane  is  thin  in  the  middle  line, 
but  is  much  thicker  at  the  sides  near  the  alveoli,  the 
increased  thickness  depending  mainly  upon  the  in- 
troduction of  a  number  of  mucous  glands  beneath  the 
surface  layers,  such  glands  being  absent  in  the  middle 
line.  The  density  and  toughness  of  the  soft  covering 
of  the  hard  palate  render  it  very  easy  to  manipulate 
when  dissected  up  in  the  form  of  flaps  in  the  opera- 
tion for  the  cleft  palate. 

The  main  blood  supply  of  both  the  bones  of  the 
hard  palate  and  its  mucous  covering  is  derived  from 
the  descending  palatine  branch  of  the  internal  maxil- 
lary artery.  This  vessel,  which  is  practically  the  only 
vessel  of  the  hard  palate,  emerges  from  the  posterior 
palatine  canal  near  the  junction  of  the  hard  palate 
with  the  soft,  and  close  to  the  inner  side  of  the  last 
molar  tooth.  The  vessel  runs  forwards  and  inwards, 
to  end  at  the  anterior  palatine  canal.  Its  pulsations  ou 
J— 4 


130  SURGICAL  APPLIED  ANATOMY.  [CJiap.  vin. 

the  palate  can  often  be  distinctly  felt.  In  dissecting  up 
muco-periosteal  flaps  from  the  hard  palate,  it  is  most 
important  to  make  the  incision  in  the  mucous  mem- 
brane, close  to,  and  parallel  with,  the  alveolus,  so  that 
this  artery  may  be  included  in  the  flap  and  its  vitality 
therefore  not  be  endangered.  By  such  an  incision, 
also,  unnecessary  bleeding  is  avoided.  In  dissecting 
up  the  flap  it  should  be  remembered  that  the  artery 
runs  much  nearer  to  the  bone  than  to  the  mucous 
surface. 

The  soft  palate  is  of  uniform  thickness,  its 
average  measurement  being  estimated  at  about  a 
quarter  of  an  inch.  When  the  soft  palate  is  cleft,  the 
edges  of  the  fissure  are  approximated  during  swallow- 
ing by  the  uppermost  fibres  of  the  superior  constrictor. 
This  approximation  may  narrow  the  cleft  to  one-third 
or  one-half  of  its  previous  size.  The  muscles  that 
tend  to  widen  the  cleft  are,  in  the  main,  the  levator 
palati  and  tensor  palati.  It  is  necessary  that  these 
muscles  should  be  divided  before  attempting  to  close 
the  cleft  by  operation.  The  levator  palati  crosses  the 
palate  obliquely  from  above  downwards  and  inwards 
on  its  way  to  the  middle  line,  lying  nearer  to  the 
posterior  than  the  anterior  surface  of  the  velum.  The 
tensor  palati  turns  round  the  hamular  process,  and 
passes  to  the  middle  line  in  a  nearly  horizontal  direc- 
tion. The  hamular  process  can  be  felt  through  the 
soft  palate  just  behind  and  to  the  inner  side  of  the  last 
upper  molar  tooth.  There  are  three  principal  methods 
of  dividing  these  muscles  :  (1)  Ferguson's :  A  small 
knife,  with  the  blade  at  right  angles  to  the  stem,  is 
passed  through  the  cleft,  and  is  made  to  divide  the 
levator  palati  by  an  incision  on  the  posterior  aspect 
of  the  palate,  transverse  to  the  direction  of  the  muscle. 
The  tensor  is  not  divided  in  this  procedure.  (2) 
Pollock's  :  A  thin  narrow  knife,  with  the  cutting 
edge  upwards,  is  introduced  into  the  soft  palate  a  little 


Chap.  VIII.J 


THE  PHARYNX. 


iu  front,  and  to  the  inner  side  of  the  hamular  process. 
The  tendon  of  the  tensor  muscle  is  above  the  knife, 
and  is  cut  as  the  knife  is  pushed  upwards  and  inwards. 
The  knife  is  inserted  until  its  point  presents  at  the 
upper  part  of  the  cleft.  As  it  is  being  withdrawn,  it 

is    made   to   cut   the    posterior 

surface  of  the  velum  to  a  suffi- 
cient depth  to  divide  the  levator 
palati  (Fig.  14).  (3)  Bryant's  : 
Here  the  palate  muscles  are 
divided  by  a  cut  with  the 
scissors  that  involves  the  entire 
thickness  of  the  velum,  the  cut 
being  at  the  side  of  the  velum, 
and  nearly  parallel  with  the 
cleft. 

The  blood  supply  of  the  soft 
palate  is  derived  from  the  des- 
cending palatine  branch  of  the 
internal  maxillary  artery,  the 
ascending  pharyngeal  artery, 
and  the  ascending  palatine 
branch  of  the  facial  artery.  The 
latter  vessel  reaches  the  velum 
by  following  the  levator  palati  muscle,  and  must  be 
divided  in  the  section  made  of  this  muscle  in  the 
procedures  just  described. 

It  would  appear  that  the  nerve  supply  of  the 
levator  palati  is  derived  from  the  spinal  accessory 
and  not  from  the  facial  or  fifth  nerve. 

The  pharynx  is  about  five  inches  in  length.  It 
is  much  wider  from  side  to  side  than  from  before 
backwards.  It  is  widest  at  the  level  of  the  tip  of  the 
greater  cornua  of  the  hyoid  bone,  where  it  measures 
about  two  inches.  It  is  narrowest  where  it  joins  the 
gullet  opposite  the  cricoid  cartilage,  its  diameter  here 
being  less  than  three-quarters  of  an  inch.  The 


ig. 

the    Soft  Palate,  from 

behind. 

a,  Levator  palati :  6,  tensor 
palati ;  c.  hanutlar  process; 
d,  wall  of  pharynx  ;  e,  azy- 
gos  11  viihr  ;  /,  t  lir  point  of 
entry  of  the  knife  in  Pol- 
lock s  operation  ;  aliove  it 
is  the  lino  of  incision  made 
ou  withdrawing  the  knife. 


132  SURGICAL  APPLIED  ANATOMY.   [Cnap. vm. 

pharynx  is  not  so  large  a  space  as  supposed,  for  it 
must  be  remembered  that  during  life  it  is  viewed 
very  obliquely,  and  erroneous  notions  are  thus  formed 
of  its  antero-posterior  dimensions.  The  distance  from 
the  arch  of  the  teeth  to  the  commencement  of  the 
gullet  is  about  six  inches,  a  measurement  that  should 
be  borne  in  mind  in  extracting  foreign  bodies.  Foreign 
bodies  passed  into  the  pharynx  are  most  apt  to  lodge 
at  the  level  of  the  cricoid  cartilage,  a  point  that,  in 
the  adult,  is  a  little  beyond  the  reach  of  the  finger. 
The  history  of  foreign  bodies  in  the  pharynx  shows 
that  that  cavity  is  very  dilatable,  and  can  accommo- 
date for  some  time  large  substances.  Thus,  in  a  case 
reported  by  Dr.  Geoghegan,  a  man  of  sixty,  who  had 
for  months  some  trouble  in  his  throat  for  which  he 
could  not  account,  was  supposed  to  have  cancer.  On 
examination,  however,  a  plate  carrying  five  false 
teeth,  and  presenting  niches  for  five  natural  ones,  was 
found  embedded  in  the  pharynx,  where  it  had  been 
lodged  for  five  mouths.  The  plate  had  been  swallowed 
during  sleep  (Med.  Press,  1866).  In  the  Lancet  for 
1868  is  an  account  of  a  mutton  chop  that  became 
lodged  in  the  pharynx  of  a  gluttonous  individual. 
The  chop  presented  the  ordinary  vertebral  segment  of 
bone,  together  with  one  and  a  half  inches  of  rib,  and 
was  "pretty  well  covered  with  meat."  Attempts  to 
remove  it  failed,  and  it  was  finally  vomited  up.  Dr. 
Hicks  (Lancet,  1884)  reports  the  case  of  a  woman  who 
committed  suicide  by  cramming  one-half  a  square  yard 
of  coarse  calico  (belonging  to  her  night-dress)  into  her 
mouth  and  throat. 

The  walls  of  the  pharynx  are  in  relation  with  the 
base  of  the  skull,  and  with  the  upper  six  cervical 
vertebrae.  The  arch  of  the  atlas  is  almost  exactly  on  a 
line  with  the  hard  palate.  The  axis  is  on  a  line  with 
the  free  edge  of  the  upper  teeth.  The  termination 
of  the  pharynx  corresponds  to  the  sixth  cervical 


Chap,  viii.]  THE  PHARYNX.  133 

vertebra.  The  upper  vertebrae  can  be  examined,  as 
regards  their  anterior  surface,  from  the  mouth.  When 
the  bones  about  the  pharynx  are  diseased,  the  necrosed 
parts  may  be  discharged  by  that  cavity.  Thus  por- 
tions of  the  atlas  and  axis  have  been  expelled  by  the 
mouth,  as  have  also  been  some  fragments  of  compara- 
tively lai'ge  size  thrown  off  by  the  occipital  and 
sphenoid  bones. 

The  mucous  membrane  of  the  pharynx  is  vascular, 
and  readily  inflamed  ;  and  such  inflammations  are 
peculiarly  dangerous,  in  that  they  may  spread  to  the 
lining  membrane  of  the  larynx.  Much  adenoid  tissue 
is  distributed  in  the  mucous  membrane  of  the  pharynx, 
and  it  is  this  tissue  that  is  the  primary  seat  of  inflam- 
mation in  scrofulous  pharyngitis.  A  distinct  collec- 
tion of  adenoid  tissue  stretches  across  the  hinder  wall 
of  the  pharynx  between  the  openings  of  the  Eustachian 
tubes.  It  is  known  as  Luschka's  tonsil,  or  the  pharyn- 
geal  tonsil.  This  deposit  of  adenoid  tissue  may  under- 
go hypertrophic  change  and  the  condition  known  as 
"  adenoid  vegetations  "  or  "  post-nasal  growths  "  be 
produced.  These  growths  may  cause  deafness,  and 
may  block  the  posterior  nares.  They  need  to  be  re- 
moved by  operation.  The  tissue  immediately  outside 
the  pharynx  walls  is  lax,  and  favours  the  spread  of 
effusion.  Thus,  in  acute  inflammation  of  the  pharynx 
the  effusion  has  been  found  to  extend  along  the 
oesophagus,  reaching  the  posterior  mediastinum,  and 
advancing  even  to  the  diaphragm.  In  the  lax  con- 
nective tissue  between  the  pharynx  and  the  spine 
abscess  is  nob  infrequent,  due,  as  a  rule,  to  caries  of 
the  vertebrae  (post-pharyngeal  abscess).  In  this  con- 
nective tissue,  and  opposite  the  axis,  is  also  found  a 
lymphatic  gland  that  receives  lymphatics  from  the 
nares.  This  gland  may  prove  the  seat  of  a  suppura- 
tion. Such  collections  may  so  push  forward  the  pos- 
terior pharyngeal  wall  as  to  depress  the  soft  palate, 


134  SURGICAL  APPLIED  ANATOMY.  [Chap.  vin. 

or  may  cause  severe  dyspnoea  by  interference  with  the 
larynx.  The  matter  may  discharge  itself  through  the 
mouth,  or  may  reach  the  neck  by  passing  behind  the 
great  vessels  and  the  parotid  gland,  presenting  ulti- 
mately beneath  or  at  one  border  of  the  sterno-mastoid 
muscle. 

Many  structures  of  importance  are  in  relation  with 
the  lateral  walls  of  the  pharynx,  the  principal  being  the 
internal  cai'otid  artery,  the  vagus,  glosso-pharyngeal, 
and  hypoglossal  nerves.  The  internal  carotid  is  so 
close  to  the  pharynx  that  its  pulsations  may  be  felt 
by  the  finger  introduced  through  the  mouth.  These, 
and  other  deep  structures  in  the  neck,  may  be  wounded 
by  foreign  bodies,  that,  passing  in  at  the  mouth,  have 
been  thrust  through  the  pharynx  into  the  cervical 
tissues.  The  internal  jugular  vein  is  at  some  distance 
from  the  pharynx,  especially  at  its  upper  part  (Fig. 
13).  Langenbeck  has  three  times  extirpated  the  pha- 
rynx for  malignant  disease,  but  without  success.  He 
reaches  it  from  the  neck  through  an  incision,  that, 
beginning  below  the  jaw,  midway  between  the  sym- 
physis  and  angle,  is  carried  over  the  great  cornu  of 
the  hyoid  bone,  and  ends  close  to  the  cricoid  cartilage. 
The  posterior  belly  of  the  digastric  and  the  stylo-hyoid 
muscles  are  detached  from  the  hyoid  bone,  while  the 
omo-hyoid  muscle,  the  lingual,  facial,  and  superior 
thyroid  arteries,  and  the  superior  laryngeal  nerve  are 
divided. 

The  tonsil  is  lodged  between  the  anterior  and 
posterior  palatine  arches.  It  is  in  relation  externally 
with  the  superior  constrictor  muscle,  and  corresponds, 
as  regards  the  surface,  to  the  angle  of  the  lower  jaw. 
It  is  questionable  whether  the  enlarged  tonsil,  when 
it  is  the  subject  of  other  than  malignant  enlargement, 
can  ever  be  felt  externally.  When  hypertrophied,  the 
mass  tends  to  develop  towards  the  middle  line,  where 
no  resistance  is  encountered,  and  to  effect,  but  little 


Chap,  viii.i  THE  PHARYNX.  135 

change  in  its  external  relations.  The  mass,  often  mis- 
taken for  the  enlarged  tonsil  in  the  neck,  is  formed  of 
enlarged  glands,  situate  near  the  tip  of  the  great  cornu 
of  the  hyoid  bone.  These  glands  receive  the  tonsillar 
lymphatics,  and  are  almost  invariably  enlarged  in  all 
tonsil  affections.  It  must  be  remembered  that  many 
structures  are  interposed  between  the  tonsil  and  the 
skin,  and  as  the  hypertrophied  body  projects  freely 
into  the  pharyngeal  cavity,  one  would  not  expect  (hat 
it  could  be  readily  felt,  even  were  the  interposed 
tissues  less  extensive  than  they  are.  The  tonsil  is 
closely  enough  attached  to  the  pharyngeal  wall  to  be 
affected  by  the  movements  of  the  pharyngeal  muscles. 
Thus  it  is  moved  inwards  by  the  superior  con- 
strictor muscle  during  the  act  of  swallowing,  and  may 
be  drawn  outwards,  on  the  other  hand,  by  the  stylo- 
pharyngeus  muscle.  The  ease  with  which  a  tonsil  can 
be  reached  depends,  other  things  being  equal,  upon 
the  extent  to  which  it  can  be  withdrawn  by  the  stylo- 
pharyngeus,  and  upon  the  development  of  the  anterior 
palatine  arch,  which,  to  some  extent,  hides  the  tonsil. 
A  child  with  a  prominent  anterior  palatine  arch,  con- 
taining a  well- developed  palato-glossus  muscle,  and 
with  a  vigorous  stylo-pharyngeus,  can  for  a  long  time 
elude  the  tonsil  guillotine. 

Deafness  is  often  complained  of  when  the  tonsil  is 
hypertrophied.  This  is  not  due  to  closure  of  the 
Eustachian  tube  by  the  direct  pressure  of  the  enlarged 
mass.  Such  pressure  is  anatomically  impossible.  The 
large  tonsil  may,  however,  affect  the  patency  of  the 
tube,  by  disturbing  the  soft  palate,  and  through  it  the 
tensor  palati  muscle,  which  is  much  concerned  in  keep- 
ing open  the  Eustachian  tube.  The  deafness  in  these 
cases  is  probably  due  rather  to  an  extension  of  the 
hypertrophic  process  to  the  lining  membrane  of  the 
tube  than  to  any  pressure  effects,  since  it  is  usually 
not  improved  until  some  time  after  the  tonsil  has 


136  SURGICAL  APPLIED  ANATOMY.  [Chap. vui. 

been  removed.  The  tonsil  tissue  is  for  the  most  part 
collected  around  a  number  of  recesses.  The  decom- 
position of  retained  epithelial  structures  within  those 
recesses  produces  the  foetid  breath  often  noticed  in 
cases  of  enlarged  tonsil,  and  probably  incites  the 
attacks  of  inflammation  to  which  such  tonsils  are 
liable. 

The  tonsil  is  very  vascular,  receiving  blood  from 
the  tonsillar  and  palatine  branches  of  the  facial 
artery,  from  the  descending  palatine  branch  of  the 
internal  maxillary,  from  the  dorsalis  linguae  of  the 
lingual  and  from  the  ascending  pharyngeal.  Hence  the 
operation  of  removing  the  tonsil  is  often  associated 
with  free  bleeding.  The  internal  carotid  artery  is  close 
to  the  pharynx,  but  is  some  way  behind  the  gland 
(Fig.  13).  The  vessel  is,  indeed,  about  four-fifths  of 
an  inch  posterior  to  that  body,  and  is  in  comparatively 
little  danger  of  being  wounded  when  the  tonsil  is  ex- 
cised. The  internal  jugular  vein  is  a  considerable 
distance  from  the  tonsil.  Of  important  cervical  stnic- 
tures,  the  nearest  to  the  tonsil  is  the  glosso-pharyngeal 
nerve.  The  ascending  pharyngeal  artery  is  also  in 
close  relation  with  it.  Although  of  small  size,  bleed- 
ing from  this  vessel  has  proved  fatal,  as  the  following 
interesting  case,  reported  by  Mr.  Morrant  Baker,  will 
show :  A  man,  aged  23,  fell  when  drunk,  and  grazed 
his  throat  with  the  end  of  a  tobacco-pipe  he  was 
smoking  at  the  time.  He  thought  nothing  of  the 
accident.  In  two  days  he  came  to  the  hospital 
with  what  appeared  to  be  an  acutely  inflamed  tonsil. 
The  tonsil  was  punctured,  but  nothing  escaped  save  a 
little  blood.  Several  haemorrhages  occurred  from  the 
tonsil  wound,  and  on  the  fourth  day  after  the  accident 
one  inch  of  the  stem  of  a  clay  pipe  was  discovered 
deeply  embedded  in  the  glandular  substance.  It  was 
removed,  and  the  common  carotid  tied.  The  patient, 
however,  never  rallied  from  the  previous  severe 


Chap,  ix.]  THE  NECK.  137 

haemorrhages,  and  soon  died.  The  autopsy  showed 
that  the  stem  of  the  pipe,  which  had  not  been  missed 
by  the  patient,  had  divided  the  ascending  pharyn- 
geal  artery  (St.  Bart.'s  Hosp.  Reports,  1876). 

The  tonsil  is  often  the  seat  of  malignant  growths. 
Such  tumours  have  been  removed  through  the  mouth, 
but  are  more  conveniently  dealt  with  through  an  in- 
cision in  the  neck  along  the  anterior  edge  of  the  sterno- 
mastoid  (Cheever's  operation). 


CHAPTER  IX. 

THE  NECK. 

Surface  anatomy ;  bony  points. — The  hyoid 
bone  is  on  a  level  with  the  fourth  cervical  vertebra, 
while  the  cricoid  cartilage  is  opposite  the  sixth.  The 
upper  margin  of  the  sternum  is  on  a  level  with  the 
disc  between  the  second  and  third  dorsal  vertebrae. 
(See  page  171.)  At  the  back  of  the  neck  there  is  a 
slight  depression  in  the  middle  line  which  descends 
from  the  occipital  protuberance,  and  lies  between  the 
prominences  formed  by  the  trapezius  and  complexus 
muscles  of  the  two  sides.  At  the  upper  part  of  this 
depression  the  spine  of  the  axis  can  be  made  out  on 
deep  pressure.  Below  this,  the  bony  ridge  formed  by 
the  spines  of  the  third,  fourth,  fifth,  and  sixth  cervical 
vertebrae  can  be  felt,  but  the  individual  spines  cannot 
visually  be  distinguished.  At  the  root  of  the  neck  the 
spinous  process  of  the  vertebra  prominens  is  generally 
very  obvious.  The  transverse  process  of  the  atlas  may 
be  felt  just  below  and  in  front  of  the  tip  of  the  mastoid 
process.  By  deep  pressure  in  the  upper  part  of  the 
supraclavicular  fossa,  the  transverse  process  of  the 
seventh  cervical  vertebra  can  be  distinguished.  If 


138  SURGICAL  APPLIED  ANATOMY.     [Chap.  ix. 

deep  pressure  be  made  over  the  line  of  the  carotid 
vessels  at  the  level  of  the  cricoid  cartilage,  the  promi- 
nent anterior  tubercle  of  the  transverse  process  of  the 
sixth  cervical  vertebra  can  be  felt.  This  is  known  as 
the  "  carotid  tubercle."  The  carotid  artery  lies  directly 
over  it,  and  in  ligaturing  that  vessel  some  surgeons 
make  important  use  of  this  tubercle  as  a  landmark.  If 
a  horizontal  section  of  the  neck,  in  a  muscular  subject, 
taken  about  the  level  of  the  sixth  cervical  vertebra, 
be  viewed,  it  will  be  observed  that  the  whole  of  the 
body  of  the  vertebra  divided  will  lie  within  the  an- 
terior half  of  the  section. 

The  middle  line. — In  the  receding  angle  below 
the  chin  the  hyoid  bone  can  be  felt,  and  its  body  and 
greater  cornua  well  made  out.  About  a  finger's 
breadth  below  it  is  the  thyroid  cartilage.  The  details 
of  this  latter  are  readily  distinguished,  and  below  it 
the  cricoid  cartilage,  crico-thyroid  space,  and  trachea 
can  be  easily  recognised.  The  separate  rings  of  the 
trachea  cannot  be  felt.  The  trachea  is  less  easily  made 
out,  as  it  passes  down  the  neck.  As  it  descends  it 
takes  a  deeper  position,  and  at  the  upper  border  of 
the  sternum  lies  nearly  one  and  a  half  inches  from  the 
surfaca 

The  rima  glottidis  corresponds  to  the  middle  of  the 
anterior  margin  of  the  thyroid  cartilage. 

Unless  enlarged,  the  thyroid  gland  cannot  be  made 
out  with  certainty.  According  to  Mr.  Hold  en,  the 
pulse  of  the  superior  thyroid  artery  can  be  felt  at  its 
upper  and  anterior  part. 

The  anterior  jugular  veins  descend  on  either  side 
of  the  middle  line  upon  the  sterno-hyoid  muscles. 
They  commence  in  the  submaxillary  region,  pierce  the 
fascia  just  above  the  inner  end  of  the  clavicle,  and, 
passing  behind  the  origin  of  the  sterno-mastoid 
muscle,  are  lost  to  view.  The  inferior  thyroid  veins 
lie  in  front  of  the  trachea,  below  the  isthmus. 


Chap,  ix.]  THE  NECK.  139 

The  side  of  the  neck. — Muscles.  The  stemo- 
mastoid  muscle,  especially  in  thin  subjects  and  when 
thrown  into  action,  is  a  prominent  feature  in  the 
neck.  The  anterior  border  of  the  muscle  is  very 
distinct.  The  posterior  border  is  less  prominent, 
especially  at  its  upper  part.  A  communicating  branch 
from  the  facial  vein  generally  runs  along  the  anterior 
border  of  the  muscle  to  meet  the  anterior  jugular  vein 
at  the  lower  part  of  the  neck.  The  interval  between 
the  sternal  and  clavicular  parts  of  the  muscle  is 
generally  well  marked.  If  a  needle  be  thrust  through 
this  interval,  quite  close  to  the  clavicle,  it  would  just 
touch  the  bifurcation  of  the  innominate  artery  on  the 
right  side  and  would  pierce  the  carotid  vessel  on  the 
left.  The  posterior  belly  of  the  digastric  muscle 
corresponds  to  a  line  drawn  from  the  mastoid  process 
to  the  anterior  part  of  the  hyoid  bone.  The  anterior 
belly  of  the  omo-hyoid  follows  an  oblique  line  drawn 
downwards  from  the  fore-part  of  the  hyoid  bone,  so  as 
to  cross  the  line  of  the  carotid  artery  opposite  the 
cricoid  cartilage.  The  posterior  belly  can  be  made 
out  in  thin  necks,  especially  when  in  action,  running 
nearly  parallel  with  and  just  above  the  clavicle. 
Although  not  taking  quite  the  same  direction,  yet  the 
posterior  borders  of  the  sterno-mastoid  and  anterior 
scalene  muscles  practically  correspond  to  one  another. 

Vessels. — The  common  carotid  artery  is  represented 
by  a  line  drawn  from  the  stemo-clavicular  joint  to  a 
point  midway  between  the  angle  of  the  jaw  and  the 
mastoid  process.  The  vessel  bifurcates  at  the  upper 
border  of  the  thyroid  cartilage.  The  omo-hyoid 
crosses  it  opposite  the  cricoid  cartilage,  and  at  about 
the  same  level  the  art-ery  is  crossed  by  the  middle 
thyroid  vein.  The  line  of  the  internal  jugular  vein  is 
just  external  to  that  for  the  main  artery.  The 
superior  thyroid  artery  comes  off  just  below  the  great 
cornu  of  the  hyoid  bone,  and  curves  forwards  and 


140  SURGICAL  APPLIED  ANATOMY.     [Omp.  ix 

downwards  to  the  upper  edge  of  the  thyroid  cartilage. 
The  lingual  arises  opposite  the  tip  of  the  great  cornu, 
and  runs  just  above  that  process  on  its  way  to  the 
tongue.  The  facial  artery  is  very  tortuous,  but  its 
general  course  in  the  neck  is  represented  by  a  line 
drawn  from  the  anterior  border  of  the  masseter  at  the 
lower  border  of  the  jaw  to  a  point  just  above  the  tip 
of  the  great  cornu,  while  the  occipital  follows  a  line 
that  starts  from  the  latter  point  and  runs  across  the 
base  of  the  mastoid  process. 

The  external  jugular  vein  follows  a  line  drawn 
from  the  angle  of  the  jaw  to  the  middle  of  the  clavicle. 

The  subclavian  artery  describes  a  curve  at  the  base 
of  the  posterior  triangle.  One  end  of  the  curve 
corresponds  to  the  sterno-clavicular  joint,  the  other 
end  to  the  centre  of  the  clavicle,  the  summit  of  the 
curve  rising  to  a  point  about  half  an  inch  above  that 
bone.  In  the  angle  between  the  posterior  edge  of 
the  sterno-mastoid  and  the  clavicle  the  pulsations  of 
the  artery  may  be  felt.  Just  above  the  bone  the 
artery  may  be  compressed  against  the  first  rib.  The 
compression  is  most  easily  applied  when  the  arm  is 
well  drawn  down,  and  the  direction  of  the  pressure 
should  be  downwards  and  inwards. 

The  subclavian  vein  lies  below  the  artery,  and  is 
entirely  under  cover  of  the  clavicle. 

The  suprascapular  and  transverse  cervical  arteries 
run  parallel  with  the  clavicle,  the  former  quite  behind 
the  bone,  the  latter  just  above  it.  The  pulsations  of 
the  latter  vessel  can  generally  be  felt. 

Nerves. — The  position  of  the  chief  superficial 
nerves  of  the  neck  may  be  fairly  indicated  by  six 
lines,  all  drawn  from  the  middle  of  the  posterior  border 
of  the  sterno-mastoid  muscle.  A  line  drawn  forwards 
from  this  spot  so  as  to  cross  the  sterno-mastoid  at 
right  angles  to  its  long  axis,  corresponds  to  the  super 
Gcial  cervical  nerve.  A  second  Hue  drawn  up  across 


Chap,  ix.]  THE  NECK.  141 

the  muscle  to  the  back  of  the  pinna,  BO  as  to  run 
parallel  with  the  external  jugular  vein,  corresponds  to 
the  great  auricular  nerve ;  and  a  third  line,  running 
along  the  posterior  border  of  the  sterno-mastoid 
muscle  to  the  scalp  marks  the  course  of  the  small 
occipital  nerve.  These  lines,  continued  downwards,  so 
as  to  cross  the  sternum,  the  middle  of  the  clavicle, 
and  the  acromion,  will  indicate  respectively  the  supra- 
sternal,  supraclavicular,  and  supra-acromial  nerves. 

The  spinal  accessory  nerve  reaches  the  anterior 
border  of  the  sterno-mastoid  muscle  at  a  point  about 
one  inch  below  the  tip  of  the  mastoid  process.  It 
emerges  from  beneath  that  muscle  about  the  middle 
of  its  posterior  border,  crosses  the  posterior  triangle, 
and  passes  beneath  the  edge  of  the  trapezius  at  a  spot 
on  a  level  with  the  spine  of  the  vertebra  prominens. 

The  phrenic  nerve  commences  deeply  at  the  side 
of  the  neck,  about  the  level  of  the  hyoid  bone,  and 
runs  downwards  to  a  point  behind  the  sternal  end  of 
the  clavicle.  About  the  level  of  the  cricoid  cartilage 
it  lies  beneath  the  sterno-mastoid  (which  covers  it 
wholly  in  the  neck)  about  midway  between  the  anterior 
and  posterior  borders  of  the  muscle.  The  brachial 
plexus  can  be  felt,  and  even  seen  in  very  thin  sub- 
jects. Its  upper  limits  may  be  represented  by  a  line 
drawn  across  the  side  of  the  neck  from  a  point  about 
opposite  to  the  cricoid  cartilage,  to  a  spot  a  little  ex- 
ternal to  the  centre  of  the  clavicle. 

The  neck. — The  skin  in  the  submaxillary  region 
is  lax  and  thin,  and  is  often  found  of  considerable 
value  for  making  flaps  in  plastic  operations  about  the 
mouth.  The  platysma  myoides  is  closely  connected 
with  the  skin,  and  to  its  action  is  due  the  tuming-in 
of  the  edges  of  such  wounds  as  are  athwart  the  lino 
of  direction  of  the  muscle.  The  amount  of  subcu- 
taneous fat  in  the  cervical  region  varies  in  different 
parts.  In  the  suprahyoid  region  it  is  apt  to  undergo 


142  SURGICAL  APPLIED  ANATOMY.     [Chap.  ix. 

extensive  development,  producing  the  diffused  liporaa 
known  as  "  double-chin." 

The  skin  over  the  nape  of  the  neck  is  very  dense 
and  adherent,  a,nd  these  two  circumstances,  in  addition 
to  the  free  nerve-supply  of  the  parts,  serves  to  explain 
the  severe  pain  that  often  accompanies  inflammation 
in  this  region.  Common  carbuncle  is  very  commonly 
met  with  at  the  root  of  the  neck,  in  the  middle  line. 
Why  it  especially  selects  this  spot  it  is  difficult  to 
say.  It  may  be  noted,  however,  that  this  region  has 
no  very  extensive  blood  supply,  that  the  middle  line 
of  the  body  is  in  all  parts  of  comparatively  slight 
vascularity,  and  that  at  the  nape  of  the  neck 
covered  and  uncovered  parts  of  the  body  meet,  so 
that  the  spot  is  liable  to  considerable  fluctuations 
of  temperature.  Setons  and  issues  were,  in  less 
recent  times,  often  applied  to  the  dense  integuments 
at  the  back  of  the  neck,  just  below  the  occiput. 
These  measures  were  accredited  with  not  infrequently 
producing  tetanus,  and,  in  such  cases,  it  is  probable 
that  the  nerve  irritation  started  in  the  great  occipital 
nerve. 

When  the  steriio-mastoid  muscle  of  one  side  is 
rigidly  contracted,  either  from  paralysis  of  the  opposite 
muscle  or  from  spasmodic  contraction,  or  from  some 
congenital  defect,  the  condition  known  as  wry-neck  is 
produced.  The  position  of  the  head  in  wry-neck 
illustrates  precisely  the  effect  of  the  sterno-inastoid 
when  in  full  action.  The  head  is  bent  a  little 
forwards,  the  chin  is  turned  towards  the  sound 
side,  and  the  ear  on  the  affected  side  leans  towards 
the  sterno  -  clavicular  joint.  In  many  cases  the 
trapezius  and  scalene  muscles  are  also  affected. 
Spasmodic  contraction  of  the  muscle  may  be  due 
to  reflex  iiTitation.  Thus,  it  has  accompanied  inflam- 
mation of  the  cervical  glands  in  the  posterior  triangle. 
Such  inflammation  has  irritated  some  brandies  of  thp 


Chap,  ix.)  THE  NECK.  143 

cervical  plexus,  and  the  sterno-mastoid  muscle, 
although  it  is  supplied  mainly  bj  the  spinal  accessory 
nerve,  receives  a  nerve  from  that  plexus  (viz.,  from 
the  second  cervical).  The  course  of  the  reflex  dis- 
turbance in  such  cases  is  therefore  not  difficult  to 
follow.  A  like  contraction  has  also  been  produced 
by  direct  irritation  of  the  second  cervical  nerve  in 
cases  of  disease  of  the  first  two  cervical  vertebra. 
For  the  relief  of  some  forms  of  wry-neck,  the  sterno- 
mastoid  muscle  is  divided  subcutaneously,  as  in  an 
ordinary  tenotomy  operation,  about  half-an-inch  above 
its  attachment  to  the  sternum  and  clavicle.  Two 
structures  stand  considerable  risk  of  being  wounded 
in  this  operation,  viz.,  the  external  jugular  vein  lying 
near  the  posterior  border  of  the  muscle,  and  the  ante- 
rior jugular  which  follows  its  anterior  border,  and 
passes  behind  the  muscle,  just  above  the  clavicle,  to 
terminate  in  the  first-named  vein.  With  common 
care,  there  should  be  no  risk  of  wounding  the  great 
vessels  at  the  root  of  the  neck. 

There  is  a  curious  congenital  tumour,  or  indura- 
tion, sometimes  met  with  in  this  muscle  in  the  newly 
born.  It  is  usually  ascribed  to  syphilis,  but,  in  most 
cases,  is  probably  due  to  some  tearing  of  the  muscle 
fibres  during  the  process  of  delivery. 

The  cervical  fascia. — The  layers  of  fascia  that 
occupy  the  neck,  and  that  are  known  collectively  as 
the  deep  cervical  fascia,  are  dense  structures,  having  a 
somewhat  complex  arrangement  and  a  great  amount 
of  importance  from  a  surgical  point  of  view.  This 
fascia  limits  the  growth  of  cervical  tumours  and 
abscesses,  and  modifies  the  direction  of  their  progress, 
but  I  do  not  think  that  its  effect  in  this  matter  is 
quite  so  definite  as  is  usually  maintained.  It  is  true 
that  deep-seated  cervical  abscesses  are  often  found  to 
follow  just  such  a  course  as  the  arrangement  of  the 
fasciae  would  lead  us  to  suppose,  while,  on  the  other 


144  SURGICAL  APPLIED  ANATOMY.     [Chap.  ix. 

hand,  instances  are  by  no  means  uncommon  where  the 
abscess  or  growth  appears  to  ignore  these  membranes 
and  adopt  a  course  of  its  own. 

The  deep  cervical  fascia  may  be  divided  into  (a) 
the  superficial  layer,  and  (b)  the  deeper  processes. 
(a)  The  superficial  layer  forms  a  complete  investment 
for  the  neck,  and  covers  in  all  the  cervical  structures, 
excepting  the  platysma  and  some  superficial  veins  and 
nerves,  with  the  completeness  of  a  perfectly-fitting 
cravat  It  commences  behind  at  the  spinous  processes 
of  the  vertebra,  and,  having  invested  the  trapezius 
muscle,  starts,  at  the  anterior  border  of  that  muscle, 
as  a  single  layer,  to  cross  the  posterior  triangle.  Ar- 
riving at  the  posterior  border  of  the  sterno-mastoid 
muscle,  it  splits,  to  enclose  that  structure,  appearing 
again  as  a  single  layer  at  the  anterior  border  of  the 
muscle,  from  whence  it  passes  to  the  middle  line  of 
the  neck  to  join  the  fascia  of  the  opposite  side, 
entirely  covering  in  on  its  way  the  anterior  triangle. 
The  part  that  occupies  the  posterior  triangle  is 
attached  above  to  the  mastoid  process  and  superior 
curved  line  of  the  occipital  bone,  and  below  to  the 
clavicle,  so  that  the  space  is  completely  closed  in  by 
the  fascia  in  all  parts,  although,  just  above  the 
clavicle,  it  is  pierced  by  the  external  jugular  vein  on 
its  way  to  the  deeper  trunks.  Over  the  anterior 
triangle,  the  fascia  is  attached  above  to  the  border  of 
the  lower  jaw.  Behind  that  bone  it  passes  over 
the  parotid  gland  to  the  zygoma,  forming  the  parotid 
fascia,  while  a  deeper  layer  passes  beneath  the  gland 
(between  it  and  its  submaxillary  colleague),  to  be 
attached  to  points  at  the  base  of  the  skull.  It  is  from 
this  deeper  part  that  the  stylo-maxillary  ligament  is 
developed.  In  front  the  fascia  is  attached  to  the 
hyoid  bone,  and  just  below  the  thyroid  body  it 
divides  into  two  layers  again,  one  to  be  attached  to 
the  front  of  the  sternum,  and  the  other  to  tlie  back. 


Cha;.    IX  ] 


THE  NECK. 


Both  these  layers  lie  in  front  of  the  depressoi's  of  the 
hyoid  bone,  and  they  form  between  them  a  little 
space  (which  extends  so  far  laterally  as  to  enclose  the 
sternal  head  of  the  sterno-mastoid),  the  widest  part  of 
which  is  below,  and  which  there  corresponds  in  width 


Fig.  15. — Transverse  Section  through  the  lower  part  of  the  Neck,  to 
show  the  arrangements  of  the  Cervical  Fascia  (Diagrammatic). 

a,  Trapezitis;  i,  sterno-mastoid;  r,  depressors  of  hyoid  bone;  <t,  platysmn: 
e,  anterior  spinal  muscles :  /,  scalenus  anticus  ;  g,  carotid  artery  ;  *.  external 
jugular  vein  ;  i,  posterior  spinal  muscles ;  T,  trachea,  with  gullet  behind  and 
thyroid  body  in  front. 


to  the  thickness  of  the  sternum.  It  will  be  perceived 
that,  in  dividing  the  sternal  head  of  the  sterno- 
mastoid,  the  operation  is  performed  within  this  little 
chamber  formed  by  the  two  layers  just  named,  and  it 
is  well  to  note  that  the  anterior  jugular  vein  also 
occupies  this  chamber  on  its  way  to  the  external 
jugular  trunk.  This  superficial  layer  of  the  fascia, 
considered  generally,  would  oppose  in  all  parts  the 
K— 4 


f46  SURGICAL  ATPLIED  ANA  TO  MY.     [Chap.  ix. 

progress  of  abscesses  or  growths  towards  the  surface, 
and  would  encourage  or  compel  them  to  take  a  deeper 
position. 

(6)  The  deeper  processes.  (1)  From  the  super- 
ficial layer,  a  process  comes  off  near  the  anterior 
border  of  the  sterno-ma-stoid  muscle,  which,  passing 
beneath  the  depressors  of  the  hyoid  bone,  invests 
the  thyroid  body  and  front  of  the  trachea,  and 
passes  down,  in  front  of  that  tube  and  of  the 
large  vessels,  to  the  fibrous  layer  of  the  pericar- 
dium. (2)  The  prevertebral  fascia  is  a  layer  that 
descends  on  the  prevertebral  muscles  behind  the 
pharynx  and  gullet.  It  is  attached  above  to  the  base 
of  the  skull,  and,  below,  descends  into  the  thorax, 
behind  the  oesophagus.  Laterally,  it  joins  the  carotid 
sheath,  and  is  then  prolonged  outwards  and  down- 
wards over  the  scalene  muscles,  the  brachial  plexus, 
and  subclavian  vessels.  It  follows  these  vessels 
beneath  the  clavicle,  where  it  forms  the  axillary 
sheath,  and  becomes  connected  with  the  under  surface 
of  the  costo-coracoid  membrane.  (3)  The  sheath  of 
the  carotid  artery  and  its  accompanying  vein  and 
nerve  are  derived  in  part  from  fascia  No.  1,  and  in 
part  from  fascia  No.  2. 

The  effects  of  this  disposition  of  the  fascia  may  be 
illustrated  by  noting  the  course  probably  taken  by 
cervical  abscesses  in  various  positions.  (1)  An  abscess 
in  the  posterior  triangle  will  be  bounded  towards  the 
surface  by  the  superficial  layer  of  fascia.  Towards 
the  floor,  or  deep  part,  of  the  triangle  it  will  be 
bounded  by  the  lateral  portion  of  fascia  No.  2.  The 
abscess  may  extend  some  way  under  the  clavicle  until 
arrested  by  the  union  of  the  costo-coracoid  membrane 
with  fascia  No.  2.  It  would  readily  extend  under  the 
edge  of  the  trapezius  muscle,  and  could  pass  beneath 
the  sterno-mastoid  muscle  and  carotid  artery  to  the 
anterior  and  deeper  parts  of  the  neck.  (2)  An  abscess 


chap,  ix.]  THE  NECK.  147 

in  the  anterior  triangle  in  front  of  the  depressoi-s  of 
the  hyoid  bone  would  probably  come  forward,  owing 
to  the  thinness  of  the  fascia  in  front  of  it;  but,  if 
pent  up,  it  would  tend  to  progress  towards  the 
anterior  mediastinum,  or  into  the  lateral  parts  of  the 
neck  in  front  of  the  carotid  vessels.  (3)  An  abscess 
behind  the  hyoid  depressors  and  about  the  trachea  or 
thyroid  body,  or  in  the  immediate  vicinity  of  the 
carotid  vessels  (an  abscess  situate,  in  fact,  between 
the  deep  fasciae  Nos.  1  and  2)  would  find  itself  in 
a  narrow  strait,  and,  after  pressing  much  upon 
adjacent  parts,  would  most  readily  spread  down- 
wards into  the  mediastinum.  (4)  An  abscess  imme- 
diately in  front  of  the  spine,  and  beneath  the  deep 
fascia  No.  2,  might  extend  down  into  the  posterior 
mediastinum,  or  move  towards  the  posterior  and 
lateral  parts  of  the  neck,  following  the  brachial 
plexus,  and  so  reach  the  posterior  triangle,  or  even 
the  axilla. 

In  many  cases  a  cervical  abscess  has  burst  into  the 
gullet,  or  trachea,  and  even  into  the  pleura.  In  some 
instances  the  great  vessels  have  been  opened  up.  In 
one  remarkable  case  reported  by  Mr.  Savory  (Med. 
Chir.  Trans.,  1881),  not  only  was  a  considerable 
portion  of  the  common  carotid  artery  destroyed  by 
the  abscess,  but  also  a  still  larger  portion  of  the 
internal  jugular  vein,  and  a  large  part  of  the  vagus 
nerve.  This,  and  like  examples  of  the  destructive 
action  of  some  cervical  abscesses,  depend,  no  doubt, 
upon  the  unyielding  character  of  the  cervical  fascia, 
which  hems  in  the  pus  on  all  sides,  and  drives  it 
to  resort  to  desperate  measures  to  effect  an  escape. 
"  It  is  noteworthy,"  remarks  Mr.  Jacobson,  "  that 
communications  between  abscesses  and  deep  vessels 
have  usually  taken  place  beneath  two  of  the  strongest 
fasciae  in  the  body,  the  deep  cervical  fascia  and  the 
fascia  lata  "  (Hilton's  "  Rest  and  Pain  "I 


148  SURGICAL  APPLIED  ANATOMY,     tchnp.  ix. 

The  apex  of  the  lung  extends  into  the  neck, 
and  reaches  a  point  from  one  to  two  inches  above  the 
anterior  end  of  the  first  rib.  It  lies  behind  the  clavicle, 
anterior  scalene  muscle,  and  subclavian  vessels.  The 
right  lung  commonly  extends  higher  up  than  the 
left. 

The  pleura  has  been  opened  in  careless  operations 
on  the  subclavian  artery,  and  has  also  been  torn  in 
dragging  deep-seated  tumours  from  the  base  of  the 
nock.  The  pleura  and  lung  have  been  wounded  in 
stabs  of  the  neck  and  by  fragments  of  bone  in  severe 
fractures  of  the  clavicle.  Cervical  abscesses  have  opened 
into  the  pleura,  and,  apart  from  this,  pleurisy  has  fol- 
lowed inflammation  of  the  cellular  tissue  at  the  root  of 
the  neck. 

Hernia  of  the  lung  into  the  neck  has  occui-red 
during  violent  coughing,  an  appreciable  tumour  being 
produced  (Dr.  Knox,  Lancet,  vol.  i. ;  1885). 

Cervical  ribs. — These  structures  have  led  to 
many  errors  in  diagnosis,  have  been  mistaken  for  ex- 
ostoses,  and  where  the  subclavian  artery  is  carried 
over  them  have  led  to  the  diagnosis  of  aneurism.  They 
are  met  with  at  all  ages  and  in  both  seses,  and  repre- 
sent the  cervical  ribs  of  lower  mammals.  As  a  rule, 
one  such  rib  is  found  on  either  side  of  the  seventh 
cervical  vertebra;  sometimes  it  is  movable,  sometimes 
it  is  ankylosed  to  the  vertebra  and  its  transverse 
process.  It  may  be  very  short,  and  represented  only 
by  a  head,  neck,  and  tubercle.  Such  forms  have  been 
mistaken  for  exostoses.  It  may  be  long,  and  may  then 
end  free,  or  be  joined  to  the  first  rib,  or  the  first 
costal  cartilage  by  ligament,  or  even  by  cartilage. 
In  such  instances  the  subclavian  artery  passes  over 
the  cervical  rib,  and  its  distinct  pulsation  under  such 
circumstances  has  led  to  the  diagnosis  of  aneurism. 
To  the  longer  cervical  ribs  the  scalenus  anticus,  and 
possibly  the  scalenus  medius,  may  be  attached. 


chap,  ix.i  THE  NECK.  149 

In  tliin  subjects  the  rib  forms  a  distinct  projection 
in  the  neck. 

Cut  throat  and  wounds  of  the  neck. — The 

skin  of  the  neck  is  so  elastic  and  mobile  that  it  is 
readily  thrown  into  folds  when  a  knife,  and  especially 
a  blunt  knife,  is  drawn  across  it.  Thus,  in  cases 
of  cut  throat  several  distinct  skin  cuts  may  be  found 
that  were  all  produced  by  one  movement  of  the  knife. 
The  wound  in  cut  throat,  whether  suicidal  or  homi- 
cidal, most  frequently  involves  the  thyro-hyoid 
membrane,  next  in  frequency  the  trachea,  and  then 
the  thyroid  cartilage. 

1.  If   the   wound   be  above  the  hyoid   bone  the 
following  parts  may  be  cut :  Anterior  jugular  vein ; 
anterior  belly  of  digastric ;  mylo-hyoid,  genio-hyoid, 
genio-hyo-glossus,  and  hyo-glossus  muscles  ;  the  lingual 
artery  ;  branches  of  the  facial  artery  ;  the  hypoglossal 
and  gustatory  nerves  ;  the  submaxillary  gland.      The 
substance  of  the  tongue  may  bo  cut,  and  the  floor  of 
the  mouth  freely  opened.      In  any  case  where  the 
attachments  of  the    tongue  are  divided  the  organ  is 
apt  to  fall  back  upon  the  larynx  and  produce  suffoca- 
tion. 

2.  If  the  wound  be  across  the  thyro-hyoid  space 
the  following  may  be  the  parts  cut  :  Anterior  jugular 
vein ;  sterno-hyoid,  thyro-hyoid,  omo-hyoid  muscles  ; 
thyro-hyoid  membrane;  inferior  constrictor;  superior 
laryngeal    nerve ;    superior   thyroid    artery ;    and    if 
near  hyoid  bone  the  trunk  of  the  lingual  artery  may 
be  cut.     The  pharynx  would  be   opened    in.  a  deep 
\vound,    and    the    epiglottis   divided    near    its   base. 
Division  of  the  epiglottis  in  wounds  in  this  situation 
is  always  a  serious  complication. 

3.  If  the  wound  involve  the  ti-achea  the  following 
may  be  the  parts  cut :  Anterior  jugular  vein ;  sterno- 
hyoid,  sterno-thyroid,  and  omo-hyoid  muscles  ;  part  of 
sterno-mastoid ;    thyroid  gland  ;   superior  and  inferior 


150  SURGICAL  APPLIED  ANATOMY.     [Chap. ix. 

thyroid  arteries ;  superior,  middle,  and  inferior  thyroid 
veins  ;  recurrent  nerves  and  the  gullet. 

In  wounds  of  the  neck  the  great  vessels  often 
escape  in  a  marvellous  manner.  They  are  protected 
in  part  by  the  depth  at  which  they  are  situated,  and 
in  part  by  their  great  mobility,  lying  as  they  do  in  an 
atmosphere  of  loose  connective  tissue.  Dieffenbach 
relates  a  case  of  cut  throat  in  which  both  gullet  and 
trachea  were  divided  without  any  damage  to  the 
great  vessels.  In  cut  thi'oat  the  vessels  are  greatly 
protected  by  the  projecting  thyroid  cartilage  above, 
and  by  the  contracting  of  the  sterno-mastoid  muscles 
below.  Deep  gashes  made  across  the  crico-thyroid 
space,  or  through  the  upper  part  of  the  trachea, 
reach  the  great  vessels  more  easily  than  would  wounds 
made  with  equal  force  in  any  other  part  of  the 
neck. 

In  some  cases  of  gunshot  wound  the  vessels  seem 
to  have  been  actually  pushed  aside,  and  to  have  owed 
their  safety  to  their  mobility.  Thus,  in  a  case 
reported  by  Longmore,  the  bullet  passed  entirely 
through  the  neck  from  one  side  to  the  other.  It 
passed  through  the  gullet,  damaged  the  posterior  part 
of  the  larynx,  but  left  the  great  vessels  intact.  In 
another  recorded  case  a  boy  fell  upon  the  point  of  a 
walking-stick.  The  end  of  the  stick  passed  entirely 
through  the  neck  from  side  to  side,  entering  in  front 
of  one  sterno-mastoid  muscle,  and  emerging  through 
the  substance  of  the  opposite  one.  It  probably  passed 
between  the  pharynx  and  the  spine.  The  boy,  who 
left  the  hospital  well  in  eighteen  days,  owed  his  safety 
to  the  laxity  of  the  cervical  connective  tissue,  and  to 
the  mobility  of  the  main  structures  in  the  neck. 

In  connection  with  the  subject  of  wounds  of  the 
neck  it  must  be  remembered  that  the  most  important 
part  of  the  spinal  cord  can  be  reached  from  behind, 
through  the  gap  between  the  atlas  and  axis.  In  this 


chap.  ix.j  THE  NECK.  151 

situation  the  cord  has  been  divided  by  one  stab  of  a 
knife,  the  instrument  entering  between  the  two  bones. 
Larigier  gives  some  ingenious  cases  of  infanticide 
whei-e  the  lethal  weapon  was  merely  a  long  needle. 
The  needle  was  introduced  into  the  spinal  canal 
between  the  atlas  and  axis,  and  the  cord  readily  cut 
across. 

Wounds  at  the  side  of  the  neck  have  divided 
considerable  portions  of  the  brachial  plexus  without 
involving  other  structures. 

The  liyoid  bone  may  be  broken  by  direct 
violence,  as  from  blows,  or  in  the  act  of  throttling. 
It  is  sometimes  found  broken  in  those  who  have  been 
hanged.  The  fracture  may  involve  the  body  of  the 
bone,  but  more  usually  the  greater  cornu  is  found 
broken  off'.  In  the  New  York  Medical  Record  (1882) 
is  the  report  of  the  case  of  a  man  who  felt  something 
snap  under  his  chin  while  yawning.  On  examination 
the  hyoid  bone  was  found  to  be  fractured.  The  bone 
was  also  found  broken  in  a  patient  who  threw  her 
head  violently  backwards  to  save  herself  from  falling 
(Hamilton).  The  fracture  is  associated  with  great 
difficulty  and  pain  in  speaking,  in  moving  the  tongue, 
in  opening  the  mouth,  and  in  swallowing,  symptoms 
that  may  be  readily  understood.  A  bursa  lies  be- 
tween the  thyro-hyoid  membrane  and  the  posterior 
surface  of  the  hyoid  bone.  It  may,  when  enlarged, 
form  one  of  the  cystic  tumours  of  the  neck. 

The  larynx  and  trachea. — The  position  of  the 
larynx  in  the  neck  is  influenced  by  age.  In  the  adult 
the  crJQQJd  cartilage  reaches  to  the  lower  part  of  the 
sixth  cervical  vertebra.  In  a  child  of  three  months 
it  reaches  the  lower  border  of  the  fourih  cervical,  and 
in  a  child  of  six  years  the  lower  border  of  the  fifth 
vertebra.  At  puberty  it  attains  the  adult  position. 
The  upper  end  of  the  epiglottis  in  the  adult  is  opposite 
the  lower  border  of  the  third  cervical  vertebra.  In  a 


152  SURGICAL  ATPLIKD  ANATOMY.     [Chnp.  <x. 

child  of  three  months  it  reaches  the  lower  border  of 
the  atlas,  and  at  six  years  the  lower  border  of  the 
axis  (Symington).  With  the  laryngoscope  the  follow- 
ing parts  may  be  made  out :  The  base  of  the  tongue 
and  glosso-epiglottic  ligaments  ;  the  superior  aperture 
of  the  larynx,  presenting  in  front  the  epiglottis,  at  the 
sides  the  aryteno-epiglottidean  folds  (in  which  are  two 
rounded  eminences  corresponding  to  the  cornicula  and 
cuneiform  cartilages),  and  at  the  back  the  arytenoid 
commissure  of  mucous  membrane.  Deeply  down  can 
be  seen  the  true  and  false  vocal  cords,  the  ventricle, 
the  anterior  wall  of  the  larynx,  a  little  of  the  cricoid 
cartilage,  and  more  or  less  of  the  anterior  wall  of  the 
trachea  If  the  glottis  be  very  fully  dilated  the  open- 
ings of  the  two  bronchi  may  be  dimly  seen. 

The  thyroid  and  cricoid  cartilages,  and  the 
greater  part  of  the  arytenoid,  are  in  structure  hyaline, 
as  are  the  costal  cartilages.  Like  the  last-named,  they 
are  liable  to  become  more  or  less  ossified  as  life  ad- 
vances. Ossification  commences  in  the  thyroid  and 
cricoid  cartilages  at  about  the  age  of  20,  and  in  either 
•  cartilage  the  process  commences  in  the  vicinity  of  the 
crico-thyroid  joint.  The  arytenoid  ossifies  later. 
Ossification  of  the  laryngeal  cartilages  is  more  marked 
in  males  than  in  females.  The  larger  cartilages  are 
liable  to  be  fractured  by  violence,  as  by  blows,  throt- 
tling, etc.  The  thyroid  is  the  one  most  frequently 
broken,  and  usually  in  the  median  line. 

The  riiiia  glottidis  is  the  aperture  between  the 
true  vocal  cords  in  front  and  the  bases  of  the  arytenoid 
cartilages  behind.  It  is  the  narrowest  part  of  the 
interior  of  the  larynx,  and  it  is  well  to  be  familiar 
with  its  proportions  in  reference  to  the  entrance  of 
foreign  bodies,  and  the  introduction  of  instruments. 
In  the  adult  male  the  rima  measures  nearly  one  inch 
(11  lines)  from  before  backwards  ;  from  side  to  side, 
nt  its  widest  part,  it  measures  about  one-third  of  the 


chap,  ix.}  THE  NECK.  153 

length ;  this  diameter  may  be  increased  to  one-half 
of  the  length  in  extreme  dilatation.  In  the  female 
and  in  the  male  before  puberty  the  antero-posterior 
diameter  is  from  8  to  9  lines. 

The  mucous  membrane  of  the  larynx  varies 
in  thickness  in  different  parts,  and  in  the  amount  of 
its  submucous  tissiie.  The  membrane  is  thickest,  and 
the  submucous  tissue  most  abundant,  in  the  following 
parts,  taken  in  order  of  degree  :  The  aryteno- 
epiglottidean  folds,  the  mucous  membrane  of  the 
ventricle,  the  false  cords,  and  the  laryngeal  aspect  of 
the  epiglottis.  These  are  the  parts  that  become 
most  congested  and  swollen  in  acute  laryngitis ;  and 
the  serious  condition  known  as  oedema  of  the  glottis 
depends  mainly  upon  effusion  into  the  lax  submucous 
tissue  in  the  aryteno-epiglottidean  folds.  The  affection 
known  as  "clergyman's  sore-throat  "has  an  interesting 
anatomical  basis.  The  mucous  membrane  of  the 
larynx  is  well  provided  with  mucous  glands,  whose 
function  it  is  to  keep  moist  the  parts  concerned  in 
phonation.  When  an  individual  speaks  aloud  for  a 
long  while  the  lining  of  the  larynx  tends  to  become 
dry,  on  account  of  the  large  amount  of  cold  air  that 
is  drawn  in  directly  through  the  mouth.  To  still  keep 
these  parts  moist  the  mucous  glands  have  to  exhibit 
increased  energy,  and  in  those  who  speak  much  in 
public  the  glands  may  in  time  become  so  over-worked 
as  to  inflame.  It  is  the  inflammation  of  these  glands 
that  constitutes  the  present  affection.  The  glands  are 
riot  distributed  equally  over  all  parts  of  the  larynx, 
but  are  most  numerous  in  the  membrane  covering 
the  arytenoid  cartilages  and  parts  immediately  about 
them,  the  base  of  the  epiglottis,  and  the  interior  of 
the  ventricle.  It  is  in  these  parts,  therefore,  that  the 
changes  in  chronic  glandular  laryngitis,  or  dysphonia 
clericorum,  are  most  marked. 

Excision    of  the  larynx. — The  entire  laryux 


154  SURGICAL  APPLIED  ANATOMY.     [Chap.  ix. 

has  been  removed  for  carcinomatous  disease,  but  the 
operation,  although  not  immediately  fatal,  has  not 
been  followed  by  very  satisfactory  results.  It  is 
removed  through  an  incision  in  the  middle  line.  In 
this  incision  are  divided  the  platysma,  the  fascia,  and 
the  anterior  jugular  vein.  The  larynx  is  separated 
from  its  connections,  the  following  structures  being 
divided  :  sterno-thyroid,  thyro-hyoid,  stylo-pharyngeus, 
palato-pharyngeus,  and  inferior  constrictor  muscles, 
laryngeal  branches  of  superior  and  inferior  thyroid 
arteries,  superior  and  inferior  laryngeal  nerves,  hyo- 
epiglottic  and  glosso-epiglottic  ligaments.  The  larynx 
is  then  separated  from  the  trachea,  and  is  dissected  off 
from  below  up.  In  separating  the  gullet  and  pharynx 
there  is  great  risk  of  "  button-holing "  the  former 
tube. 

Tracheotomy  and  laryiigotomy. — The  trachea 
is  about  four  and  a  half  inches  in  length,  and  from 
three-quarters  to  one  inch  in  its  extreme  width. 
It  is  surrounded  by  an  atmosphere  of  very  lax  con- 
nective tissue,  which  allows  a  considerable  degree 
of  mobility  to  the  tube.  The  mobility  of  the 
trachea  is  greater  in  children  than  in  adults,  and 
adds  much  to  the  difficulties  of  tracheotomy.  In 
this  procedure  the  windpipe  is  opened  in  the  middle 
line  by  cutting  two  or  three  of  its  rings  above, 
below,  or  through  the  isthmus  of  the  thyroid  gland. 
Since  the  trachea,  as  it  descends,  lies  farther  from  the 
surface,  and  comes  in  relation  with  more  and  more 
important  structures,  it  is  obvious  that,  other  things 
being  equal,  the  higher  in  the  neck  the  operation  can 
be  done  the  better.  The  length  of  trachea  in  the 
neck  is  not  so  considerable  as  may  at  first  appear, 
and,  according  to  Holden,  not  more  than  some  7  or  8 
of  the  tracheal  rings  (which  number  16  to  20  in  all) 
are  usually  to  be  found  above  the  sternum.  The 
distance  between  the  cricoid  cartilage  and  the  sternal 


chap,  ix.]  THE  NECK.  155 

notch  varies  greatly,  and  depends  upon  the  length  of 
the  neck,  the  age  of  the  patient,  and  the  position  of 
the  head.  If  2  inches  of  trachea  are  exposed  above 
the  sternum  when  the  head  rests  easily  upon  the 
spine,  then  in  full  extension  of  the  head  some  \  of 
an  inch  more  of  the  windpipe  will,  as  it  were,  be 
drawn  up  into  the  neck.  According  to  Tillaux,  the 
average  full  distance  between  the  cricoid  cartilage  and 
the  sternum  is,  in  the  adult,  about  2^  inches  (7  cm.). 
The  full  distance  in  a  child  between  three  and  five 
years  is  about  1£  inches  (4  cm.),  in  a  child  between 
six  and  seven  about  2  inches  (5  cm.),  and  in  children 
between  eight  and  ten  years  about  2^  inches  (6  cm.). 
As  may  be  imagined,  the  dimensions  of  the  trachea 
on  section  vary  greatly  at  different  ages,  and  even  in 
different  individuals  of  the  same  age.  This  leads  to 
the  question  as  to  the  proper  diameter  of  tracheotomy 
tubes.  Guersant,  who  has  paid  much  attention  to 
this  matter,  says  that  the  diameter  of  the  tubes  should 
run  from  6  mm.  to  15  mm.*  The  tubes  with  a 
diameter  of  from  12  mm.  to  15  mm.  are  for  adults. 
The  tubes  below  12  mm.  are  for  children,  and  are 
divided  into  four  sets. 


No.  2.  „  8  mm.  „  4  to  8         „ 

No.  3.  „  10mm.  „  8  to  12         „ 

No.  4.  „  12mm.  „  12  to  15        „ 

In  children  under  eighteen  months  the  diameter  of 
the  tube  should  be  about  4  mm. 

In  performing  tracheotomy  it  is  most  important  that 
the  head  be  thrown  as  far  back  as  possible,  and  that 
the  chin  be  kept  strictly  in  a  line  with  the  sternal 
notch,  so  that  the  relations  of  the  middle  line  of  the 
neck  be  preserved.  Full  extension  of  the  head  not 

*  The  reader  may  be  reminded  that  12  mm.  =  about  half  n.a 
inch,  and  0  mm.,  therefore,  =  about  a  quarter  of  an  inch. 


156  SURGICAL  APPLIED  ANATOMY,     ich.ip.  ix. 

only  gives  the  surgeon  increased  room  for  the  opera- 
tion, but  also  brings  the  trachea  nearer  to  the  surface, 
and  by  stretching  the  tube  renders  it  much  less 
mobile. 

In  cutting  down  upon  the  trachea  in  the  middle 
line  of  the  neck  from  the  cricoid  cartilage  to  the 
sternum  the  following  parts  are  met  with.  Beneath 
the  integument  lie  the  anterior  jugular  veins.  As 
a  rule  these  veins  lie  some  little  way  apart  on  either 
side  of  the  median  line,  and  do  not  communicate 
except  by  a  large  transverse  bi-anch  which  lies  in  the 
interfascial  space  at  the  upper  border  of  the  sternum. 
Sometimes  there  are  many  communicating  branches 
right  in  front  of  the  tracheotomy  district,  or  the  veins 
may  form  almost  a  plexus  in  front  of  the  trachea,  or 
there  may  be  a  single  vein  which  will  follow  the 
middle  line.  Then  comes  the  cervical  fascia,  enclos- 
ing the  sterno-hyoid  and  sterno-thyroid  muscles.  The 
gap  between  the  muscles  of  opposite  sides  is  lozenge- 
shaped,  and  is  such  that  the  trachea  can  be  exposed 
without  dividing  muscle  fibres.  The  isthmus  of  the 
thyroid  usually  crosses  the  2nd,  3rd,  and  4th  rings  of 
the  trachea.  Above  it  a  transverse  communicating 
branch  between  the  superior  thyroid  veins  is  sometimes 
found.  Over  the  isthmus  is  a  venous  plexus,  from 
which  the  inferior  thyroid  veins  arise,  while  below  the 
isthmus  these  veins  lie  in  front  of  the  trachea  together 
with  the  thyroidea  ima  artery  (when  it  exists).  The 
inferior  thyroid  vein  may  be  represented  by  a  single 
trunk  occupying  the  middle  line.  In  the  infant  before 
the  age  of  two  years  the  thymus  extends  up  for 
a  variable  distance  in  front  of  the  trachea.  At 
the  very  root  of  the  neck  the  trachea  is  crossed  by  the 
innominate  and  left  carotid  arteries  and  by  the  left  in- 
nominate vein ;  and  lastly,  abnormal  branches  of  the 
superior  thyroid  artery  may  cross  the  upper  rings  of 
the  windpipe. 


chap,  ix.j  THE  NECK.  157 

The  evil  of  wounding  the  thyroid  isthmus  is 
greatly  exaggerated.  I  have  frequently  divided  this 
structure  in  performing  tracheotomy  without  any  in- 
convenience resulting.  Like  other  median  raphe,  the 
middle  line  of  the  thyroid  isthmus  has  but  a  slight 
vascularity,  and  it  has  been  shown  that  one  side  of 
the  thyroid  gland  cannot  be  injected  from  the  other 
(i.e.  by  injection  that  would  cross  the  isthmus).  The 
difficulty  of  tracheotomy  in  infants  depends  upon  the 
shortness  of  the  neck,  the  amount  of  the  subcutaneous 
fat,  the  depth  at  which  the  trachea  lies,  its  small  size, 
its  great  mobility,  and  the  ease  with  which  it  can  be 
made  to  collapse  on  pressure.  To  the  finger,  roughly 
introduced,  the  infant's  trachea  offers  little  resistance. 
Its  mobility  is  such  that  we  hear  of  its  being  held  aside 
unknowingly  by  retractors,  while  the  operator  is 
scoring  the  oesophagus  (Durham).  In  the  child  also 
the  great  vessels  often  cross  the  trachea  higher  up  than 
in  the  adult,  and  some  inconvenience  may  also  arise 
from  an  unduly  prominent  thymus.  In  one  case,  in 
an  infant,  the  end  of  a  tracheotomy  tube  pressing  on 
the  front  of  the  trachea  produced  an  ulcer  that  opened 
the  innominate  artery  (Brit.  Med.  Jour.,  1885).  In 
introducing  the  cannula,  if  the  tracheal  wound  be 
missed,  it  is  easy  to  thrust  the  instrument  into  the 
lax  tissue  beneath  the  cervical  fascia  and  imagine 
that  it  is  within  the  windpipe. 

In  laryngotomy  the  air  passage  is  opened  by  a 
transverse  cut  through  the  crico-thyroid  membrane. 
The  crico-thyroid  space  only  measures  about  half  an 
inch  in  vertical  height  in  well-developed  adult  sub- 
jects, while  in  children  it  is  much  too  small  to  allow  of 
a  cannula  being  introduced.  The  crico-thyroid  arteries 
cross  the  space,  and  can  hardly  escape  division.  They 
are,  as  a  rule,  of  very  insignificant  size,  and  give  no 
trouble.  Occasionally,  however,  these  vessels  are 
large,  and  "  cases  are  recorded  in  which  serious  and 


158  SURGICAL  APPLIED  ANATOMY.      [Chap.  ix. 

even  fatal  haemorrhage  has  occurred  from  these  vessels  " 
(Durham).  In  introducing  the  cannula  it  may  readily 
slip  between  the  crico-thyroid  membrane  and  the 
mucous  lining  instead  of  entering  the  trachea. 

Foreign  bodies  often  find  their  way  into  the 
air  passages,  and  have  been  represented  by  articles  of 
food,  teeth,  pills,  buttons,  small  stones,  and  the  like. 
They  are  usually  inspired  during  the  act  of  respiration, 
and  may  lodge  in  the  superior  apertiire  of  the  larynx, 
or  in  the  rima,  or  find  their  way  into  the  ventricle, 
or  lodge  in  the  trachea,  or  enter  a  bronchus.  If  a 
foreign  substance  enters  a  bronchus  it  usually  selects 
the  right,  that  bronchus  having  its  aperture  more  im- 
mediately under  the  centre  of  tlie  trachea  than  has 
the  left  tube.  Quite  recently,  in  a  dissecting-room 
subject,  I  found  two  threepenny  pieces  lying  side  by 
side,  in  the  right  bronchus,  so  as  to  entirely  block  the 
tube.  The  danger  of  inhaled  foreign  substances  de- 
pends not  so  much  upon  the  mechanical  obstruction 
they  offer,  as  upon  the  spasm  of  the  glottis  they  excite 
by  reflex  irritation.  A  body  may,  however,  lodge  in  the 
ventricle  for  some  time  without  causing  much  trouble, 
as  in  a  case  reported  by  Desault,  where  a  cherry-stone 
lodged  for  two  years  in  this  cavity  without  much 
inconvenience  to  its  host.  In  one  strange  case  a 
bronchial  gland  found  its  way  into  the  trachea  by 
producing  ulceration  of  that  tube,  was  coughed  up, 
and  became  impacted  in  the  rima  glottidis.  The 
patient  was  saved  from  immediate  suffocation  by 
tracheotomy.  Foreign  bodies  have  been  removed 
from  the  right  bronchus  through  a  tracheotomy 
wound.  In  this  way  MacCormac  removed  from  the 
bronchus  the  blade  of  a  tooth  forceps. 

The  thyroid  body. — Each  lobe  should  measure 
about  2  inches  in  length,  about  \\  inches  in  breadth, 
and  \  of  an  inch  in  thickness  at  its  largest  part. 
When  distinctly  beyond  these  measurements  the 


Chap,  ix.]  THE  A'ECK.  157 

chyroid  may  be  considered  to  be  enlarged.  Its  usual 
weight  is  between  one  and  two  ounces.  Each  lobe 
extends  from  about  the  middle  of  the  thyroid  cartilage 
to  the  sixth  ring  of  the  trachea.  It  is  larger  in 
females  than  in  males,  and  the  right  lobe  is  usually 
larger  than  the  left.  In  connection  with  these  matters 
it  may  be  noted  that  thyroid  enlargements  (broncho- 
cele,  goitre)  are  more  common  in  females  than  in  males, 
and  in  any  case  are  more  apt  to  be  first  noticed  on  the 
right  side.  The  body  being  closely  adhei'ent  to 
the  trachea  and  larynx,  it  follows  that  it  moves 
up  and  down  dxiring  deglutition,  and  this  circum- 
stance is  of  the  utmost  value  in  the  diagnosis  of 
bronchocele  from  other  cervical  tumours.  The  thyroid 
when  enlarged  may  distort  and  narrow  the  trachea, 
and  this  is  all  the  more  likely  to  be  the  case  when  the 
enlargement  occurs  rapidly,  since  the  body  is  held 
down  by  the  sterno-hyoid,  sterno-thyroid,  and  omo- 
hyoid  muscles.  The,  enlarged  gland  is  apt  to  press 
especially  upon  the  veins  of  the  neck,  producing  en- 
gorgement of  the  face  and  head,  upon  the  sterno- 
mastoid  muscle,  and  the  other  muscles  named,  upon 
the  cervical  nerves,  and  particularly  the  recurrent 
laryngeal.  In  some  cases  of  dyspnoea  produced 
by  rapidly  growing  bronchoceles,  Bonnet  has  pro- 
.posed  subcutaneous  section  of  the  muscles.  Since 
the  isthmus  must  bind  together  the  enlarging  lobes 
of  a  bronchocele,  Sir  Duncan  Gibb,  on  the  other 
hand,  proposed  to  divide  the  isthmus  in  cases  where 
dyspnoea  resulted.  This  operation  he  performed 
several  times  with  great  relief  to  the  patient.  The 
posterior  border  of  the  thyroid  body  being  in  con- 
tact with  the  sheath  of  the  great  vessels,  it  follows 
that  the  gland  when  enlarged  may  readily  receive 
pulsations  from  those  vessels.  It  generally  touches 
also  the  lower  part  of  the  pharynx,  and  the  upper 
part  of  the  gullet  behind,  and  enlargement  in  this 


160  SURGICAL  APPLIED  ANATOMY.      [Chnr  ix. 

direction  may,  in  connection  with  the  interference  with 
the  movement  of  the  larynx  in  deglutition,  serve  to 
explain  the  difficulty  in  swallowing  often  noticed  in 
bronchocele. 

The  thyroid  gland  is  developed  about  a  diverti- 
culum,  which  is  protruded  from  the  ventral  wall  of 
the  pharynx  in  the  embryo.  The  foramen  caecum  of 
the  tongue  represents  the  spot  where  the  diverticulum 
leaves  the  pharynx.  From  this  foramen  a  duct  may 
be  found  to  lead  to  accessory  gland  masses  about  the 
hyoid  bone.  In  the  vicinity  of  this  bone  accessory 
glands  and  small  cysts  lined  with  epithelium  are  not 
infrequently  met  with.  These  glands,  together  with 
the  so-called  pyramid  or  middle  lobe,  are  the  remains 
of  the  neck  of  the  primitive  diverticulum.  The 
pyramid,  which  is  nearly  always  connected  to  the 
hyoid  bone,  exists  in  79  per  cent,  of  the  subjects 
examined  (Streckeisen). 

Atrophy  of  the  thyroid  gland,  or  its  destruction 
by  disease,  is  apt  to  lead  to  a  general  condition  of  the 
body  known  as  myxcedema.  The  condition  closely 
resembles  cretinism,  especially  as  met  with  in  goitrous 
subjects.  Myxcedema  may  follow  the  entire  excision 
of  the  gland  by  operation,  and  has  been  produced  in 
monkeys  by  experimental  removal  of  the  same.  One 
prominent  feature  in  myxcedema  is  the  swelling  of 
the  subcutaneous  tissues  from  an  accumulation 
therein  of  a  mucinoid  substance.  "  The  probable 
function  of  the  thyroid  gland,  as  established  by  ex- 
periments and  clinical  observation,  concerns,  in  the 
first  place,  the  control  of  the  mucinoid  substances  in 
the  tissues  of  the  body,  and  albuminoid  metabolism 
to  some  extent ;  and  in  the  second  place,  luemapresis. 
i.e.  manufacture  of  blood  corpuscles "  (Victor 
Horsley). 

In  excision  of  the  thyroid  gland  a  Y-shaped 
median  cut  is  usually  made  that  divides  the  skin, 


Chap,  ix.]  THE  NECK.  161 

fascia,  platysma,  and  anterior  jugular  veins.  The 
sterno-hyoid,  sterno- thyroid,  omo-hyoid,  and  portion  of 
the  sterno-mastoid  have  usually  to  be  divided.  The 
tumour  is  carefully  separated.  The  capsule  that 
invests  the  vascular  gland  must  not  be  torn  through. 
The  thyroid  vessels  are  ligatured  in  situ  before  the 
removal  of  the  mass.  The  superior  thyroid  meets 
the  gland  at  the  apex  of  the  lateral  lobe  and  is  there 
secured.  The  inferior  thyroid  artery  enters  the  lower 
part  of  the  lobe  at  its  posterior  aspect.  In  securing  this 
vessel,  and  in  liberating  the  lower  part  of  the  tumour, 
the  recurrent  laryngeal  nerve  is  in  great  danger  of 
being  damaged.  The  thyroidea  ima  artery  exists  in 
10  per  cent,  of  all  cases. 

The  gullet  commences  opposite  the  sixth  cervical 
vertebra,  and  pierces  the  diaphragm  opposite  the 
tenth  dorsal  vertebra.  It  presents  three  carves : 
one  is  antero-posterior,  and  corresponds  to  the  curve 
of  the  spinal  column ;  the  other  two  are  lateral. 
The  gullet  commencing  at  the  middle  line  deviates 
slightly  to  the  left  as  far  as  the  root  of  the  neck ; 
from  thence,  to  the  fifth  dorsal  vertebra,  it  gradually 
returns  to  the  middle  line,  and  finally  it  turns  again 
to  the  left,  at  the  same  time  passing  forwards,  to 
pierce  the  diaphragm.  Its  length  is  from  9  to  10 
inches.  Its  transverse  diameter  has  been  carefully 
estimated  by  Dr.  Mouton,  by  filling  the  gullet  with 
plaster  of  Paris  in  situ,  and  then  measuring  the  cast 
thus  obtained.  Dr.  Mouton  found  that  there  were 
three  narrow  parts  in  the  gullet,  one  at  its  com- 
mencement, one  about  2^  inches  from  that  point,  and 
a  third  where  the  tube  passed  through  the  diaphragm. 
The  diameter  at  each  of  these  points  was  a  little  over 
half  an  inch  (14  mm.);  the  diameter  elsewhere  was 
about  %  inch  (17  mm.  to  21  mm.).  By  forcible 
distension  the  two  upper  narrow  parts  could  be  dis- 
tended to  a  diameter  of  18  to  19  mm.,  the  lower  part 

L-4 


1 62  SURGICAL  APPLIED  ANATOMY.     [Chap.  ix. 

to  25  mm.,  and  the  rest  of  the  gullet  to  a  diameter  of 
nearly  1£  inches  (35  mm.).  It  follows  that  foreign 
bodies  when  swallowed  are  most  apt  to  lodge  either 
at  the  commencement  of  the  gullet  or  at  the  spot 
where  it  passes  the  diaphragm.  The  same  parts  also 
are  those  most  apt  to  show  the  effects  of  corrosives 
that  have  been  swallowed. 

Among  the  relations  of  the  oesophagus,  the  follow- 
ing may  be  noted  as  receiving  illustration  in  surgical 
practice.  The  gullet  is  in  nearly  all  its  course  in 
close  relation  with  the  front  of  the  vertebral  column. 
In  the  neck  the  trachea  is  immediately  in  front  of  it. 
In  the  thorax  it  is  in  close  connection  with  the  aorta, 
and  has  the  vena  azygos  behind  it  and  on  its  right- 
hand  side.  It  is,  moreover,  partly  in  contact  with 
both  pleurae,  but  more  especially  with  the  membrane 
of  the  right  side ;  and,  lastly,  the  recurrent  laryngeal 
nerve  ascends  between  it  and  the  trachea.  (See  Figs. 
33  and  35.) 

Now,  foreign  bodies  impacted  in  the  gullet  are 
very  apt  to  lead  to  ulcerations  that  may  open  adjacent 
parts.  Thus,  in  the  Musee  Dupuytren  is  a  specimen 
showing  a  five-franc  piece  that  had  stuck  in  the  gullet, 
and  had  produced  an  ulcer  that  had  opened  the  aorta. 
In  another  instance  a  "  smasher  "  swallowed  a  counter- 
feit half-crown  piece.  Eight  months  after  he  died  of 
haemorrhage.  The  coin  had  sloughed  into  his  aorta. 
In  another  case  (Lancet^  1871),  a  fish-bone,  lodged  in 
the  gullet  opposite  the  fourth  dorsal  vertebra,  had 
caused  two  perforating  ulcers ;  one  on  the  right  side 
had  caused  plugging  of  the  vena  azygos  major,  while 
the  other  on  the  left  had  made  a  hole  in  the  aorta. 
Less  frequently  impacted  foreign  substances  have 
found  their  way  into  the  trachea  and  into  the  posterior 
mediastinum.  Dr.  Ogle  reports  a  case  (Path.  Soc. 
Trans.,  vol.  iv.)  where  a  piece  of  bone  impacted  in  the 
gullet  induced  ulceration  of  an  intervertebral  disc  and 


Chap,  ix.]  THE  NECK.  163 

subsequent  disease  of  the  spinal  cord.  Carcinoma  of 
the  gullet,  also,  when  it  spreads,  is  apt  to  invade  ad- 
jacent parts,  and  especially  to  open  into  the  trachea  or 
bronchi  If  it  spreads  to  the  pleura,  it  will  usually 
involve  the  right  pleura,  as  being  the  membrane  more 
in  relation  with  the  gullet.  Cancer  of  the  .gullet 
has  so  spread  as  to  invade  the  thyroid  body,  the 
pericardium,  and  the  lung,  and  has  opened  up  the 
first  intercostal  artery  in  one  case,  and  the  right  sub- 
clavian  in  another  (Butlin's  "  Sarcoma  and  Carcinoma," 
1882). 

The  operation  of  cesoplmgotomy  consists  in 
incising  the  gullet  for  the  purpose  of  removing  an 
impacted  foreign  body.  The  gullet  is  usually  reached 
from  the  left  side,  since  it  projects  more  on  that 
aspect.  The  incision  is  made  between  the  sterno- 
mastoid  and  the  trachea,  in  the  same  direction  as  the 
incision  for  ligaturing  the  common  carotid.  The  cut 
extends  from  the  top  of  the  thyroid  cartilage  to  the 
sterno-clavicular  joint.  The  omo-hyoid  muscle  is 
drawn  outwards,  or  cut.  The  great  vessels,  larynx 
and  thyroid  gland,  are  drawn  aside,  and  care  must 
be  taken  not  to  wound  these  structures  nor  damage 
the  thyroid  vessels  or  the  recurrent  nerve.  The 
gullet,  when  exposed,  is  opened  by  a  vertical  inci- 
sion. 

In  cesopliagostomy  an  opening  is  made  into 
the  gullet  through  a  like  incision  in  cases  of  stricture 
of  the  tube  high  up,  the  object  being  to  feed  the 
patient  through  the  opening  made,  in  place  of  per- 
forming gastrostomy.  The  risk,  however,  of  setting 
up  severe  diffuse  inflammation  in  the  loose  planes  of 
connective  tissue  deep  in  the  neck  is  very  great,  and 
in  some  twenty-six  cases  in  which  the  operation  has 
been  already  performed  death  has,  in  nearly  all 
instances,  supervened  at  the  end  of  a  few  hours  or 
days. 


1 64  SURGICAL  APPLIED  ANATOMY,     rchap.  ix 

Great  vessels. — The  course,  relations,  and  ab- 
normalities of  the  great  cervical  vessels,  together  with 
the  operations  whereby  they  may  be  ligatured,  and 
the  details  pertaining  to  those  procedures,  are  so  fully 
given,  not  only  in  works  on  operative  surgery,  but 
also  in  the  chief  anatomical  text-books,  that  nothing 
need  be  said  upon  the  matter  in  this  place.  The 
bifurcation  of  the  common  carotid  is  a  favourite 
locality  for  aneurism,  being  a  point  where  some  re- 
sistance is  offered  to  the  blood  current.  These  tumours, 
also,  are  common  at  the  root  of  the  neck,  where  they 
are  often  due  to  extension  of  aneurismal  disease  from 
the  aorta,  although  in  many  cases  they  have  an  in- 
dependent origin.  It  is  in  the  neck  that  the  treat- 
ment of  aneurism  by  the  distal  ligature  is  most  often 
carried  out.  There  is  no  place  in  the  body  where 
Brasdor's  operation  can  be  carried  out  with  the 
completeness  with  which  it  can  be  adopted  in  the 
neck.  In  this  procedure  a  main  trunk  is  ligatured 
on  the  distal  side  of  an  aneurism,  no  branches  inter- 
vening between  the  sac  and  the  ligature.  The  cure 
by  this  measure  depends  upon  the  fact  that  blood 
does  not  continue  to  go  to  parts  when  once  the 
need  for  blood  in  them  is  diminished.  Thus,  after 
amputation  at  the  hip  joint,  the  femoral  artery,  having 
no  need  to  carry  to  the  stump  the  amount  of  blood  it 
brought  to  the  limb,  often  shrinks  to  a  vessel  no  larger 
than  the  radial.  When  an  aneurism  low  down 
in  the  carotid  artery  is  treated  by  ligature  of  the 
vessel  near  its  bifurcation  by  Brasdor's  method,  the 
blood,  having  now,  as  it  were,  no  object  in  entering 
the  carotid  trunk,  soon  ceases  to  fill  the  vessel  entirely, 
and  the  artery  (and  in  successful  cases  the  aneurism) 
shrinks  in  consequence.  Wardrop's  operation,  or  the 
distal  ligature  of  large  brandies  for  the  relief  of 
aneurism  of  a  main  trunk,  is  now,  perhaps,  quite 
limited  as  to  its  performance  to  the  ligature  of  the 


Chap,  ix.]  THE  NECK.  165 

carotid  and  subclavian  arteries  for  innominate  aneur- 
ism. Since  in  this  procedure  large  branches  come  off 
between  the  sac  and  the  ligature,  it  is  not  easy  to  fully 
understand  how  the  operation  acts  beneficially.  It  is 
assumed  to  owe  its  success  to  the  same  principle  that 
underlies  Brasdor's  operation.  The  right  carotid  and 
subclavian  have  also  been  ligatured  for  aortic  aneurism 
with  some  success,  and  here  also  the  reason  for  the 
good  effected  by  the  operation  is  difficult  to  appreciate. 
It  has  been  pointed  out  that  the  innominate  artery 
lies  more  or  less  directly  in  the  axis  of  the  ascending 
aorta,  while  the  left  carotid  and  subclavian  arteries 
arise  at  an  angle  to  that  axis,  and  it  is  upon  this  fact 
that  reasons  have  been  founded  for  selecting  the 
vessels  of  the  right  side  (Bar well).  The  matter  is, 
however,  complicated  by  the  knowledge  that  when 
vegetations  are  swept  off  the  aortic  valves  they  enter 
the  left  carotid  with  infinitely  greater  frequency  than 
they  do  the  right.  The  whole  subject,  indeed,  requires 
investigation. 

The  cervical  connective  tissue  being  lax,  aneurisms 
in  this  part  can  grow  and  spread  rapidly,  and  usually 
soon  produce  "pressure  symptoms."  As  examples  of 
these  may  be  noted  oedema  and  lividity  of  the  face  or 
the  upper  limb  from  pressure  upon  the  main  veins, 
laryngeal  symptoms  from  pressure  upon  the  recurrent 
nerve  or  trachea,  spasm  of  the  diaphragm  from  pres- 
sure upon  the  phrenic  nerve,  damage  to  the  sympa- 
thetic, and  giddiness  and  impaired  vision  from  anaemia 
of  the  brain. 

The  vertebral  artery  has  been  ligatured  with  some 
benefit  in  cases  of  epilepsy.  The  artery  is  reached 
through  an  incision  made  along  the  posterior  border 
of  the  sterno-mastoid  muscle  just  above  the  clavicle. 
The  "carotid  tubercle"  (see  page  137)  is  then  sought 
for,  and  vertically  below  it  the  artery  lies  in  the  gap 
between  the  scalenus  anticus  and  longus  colli  muscles. 


r  66  SURGICAL  APPLIED  ANATOMY.     [Chap.  ix. 

The  procedure  is  surrounded  by  considerable  diffi- 
culties. 

Dr.  Bright  and  Dr.  Ramskill  have  stated  that 
disease  involving  the  vertebral  artery  just  before  it 
enters  the  skull  may  lead  to  pain  at  the  back  of  the 
head.  It  is  well  known  that  the  suboccipital  nerve  lies 
in  close  connection  with  the  artery  over  the  posterior 
arch  of  the  atlas,  and  that  it  gives  a  branch  to  the 
great  occipital  nerve  which  is  distributed  to  the  back 
of  the  head.  The  close  connection  of  artery  and 
nerve  and  this  communicating  branch  may  serve  to 
explain  the  symptom  noted.  In  some  of  Dr.  Ram- 
skill's  cases  there  was  difficulty  of  articulation.  This 
he  ascribes  to  pressure  upon  the  hypoglossal  nerve, 
which  is  also  in  close  relation  with  the  vertebral 
artery.  The  innominate  artery  has  been  temporarily 
compressed  through  an  incision  made  in  the  median 
line  near  to  the  vessel.  The  posterior  aspect  of  the 
artery  is  exposed  and  compressed  by  the  finger  against 
the  sterno-clavicular  articulation. 

In  cases  of  bleeding  from  branches  of  the  external 
carotid  it  is  better,  when  possible,  to  ligature  the 
trunk  of  that  vessel  in  preference  to  securing  the 
common  carotid.  The  latter  procedure  has  a  high 
death  rate  (50  per  cent.)  due  (1)  to  brain  mischief, 
following  the  lessened  blood  stream  through  the 
internal  carotid,  and  (2)  to  secondary  haemorrhage, 
due  to  the  very  free  anastomosing  channels. 

Air  in  veins. — The  veins  of  the  neck  are  under 
the  influence  of  the  respiratory  movements.  During 
inspiration  these  vessels  become  more  or  less  emptied; 
during  expiration  they  become  enlarged  and  turgid. 
With  greatly  impeded  breathing  they  may  attain 
formidable  size.  Since  ether  usually  causes  some 
respiratory  difficulty,  it  is  seldom  administered  in 
operations  on  the  neck.  The  only  other  veins  that 
are  under  the  influence  of  the  aspiratory  power  of  the 


Chap,  ix.]  THE  NECK.  16? 

thorax  are  the  axillary  vein  and  its  larger  tributaries 
When  any  one  of  these  vessels  is  wounded,  and  the 
wound  is  for  the  moment  dry,  air  may  very  readily  be 
drawn  into  it  during  the  inspiratory  act,  just  as  air  is 
drawn  into  the  trachea.  Nothing  prevents  this  air 
from  being  carried  into  the  right  auricle  of  the  heart. 

The  lymphatic  glands  in  the  neck  are 
very  numerous,  and  are  arranged  in  the  following 
sets  :  (1)  Submaxillary  (10  to  15),  situate  along  the 
base  of  the  jaw  beneath  the  cervical  fascia  ;  (2)  supra- 
hyoid  (1  or  2),  situate  about  the  middle  line  of  the 
neck  between  the  chin  and  the  hyoid  bone  ;  (3)  super- 
ficial cervical  (4  to  6),  situate  along  the  external 
jugular  vein  beneath  the  platysma  ;  (4)  deep  cervical, 
upper  set  (10  to  20),  situate  about  the  bifurcation  of 
common  carotid,  and  along  the  upper  part  of  the  in- 
ternal jugular  vein ;  (5)  deep  cervical,  lower  set  (10  to 
16),  situate  about  the  lower  part  of  the  internal 
jugular  vein,  extending  outwards  into  the  supra- 
clavicular  fossa,  and  becoming  continuous  with  the 
axillary  and  mediasfcinal  glands. 

These  glands  are  veiy  often  enlarged  and  inflamed, 
and  it  is  in  this  part  of  the  lymphatic  system  that  the 
changes  in  scrofula  are  most  commonly  met  with. 
The  inflammatory  affections  in  glands  would  appear 
to  be  always  of  a  secondary  nature  (if  we  exclude 
some  cases  of  inflammation  incited  by  injury,  and 
perhaps  by  exposure  to  severe  cold),  and  to  follow 
disturbances  in  those  parts  of  the  periphery  whence 
they  respectively  receive  their  lymph.  It  may  be 
convenient,  therefore,  to  group  the  relations  of  certain 
glands  to  certain  parts  of  the  periphery. 

Scalp. — Posterior  part  =  suboccipital  and  mas- 
toid  glands.  Frontal  and  parietal  portions  =  parotid 
glands. 

Vessels  from  the  scalp  also  enter  the  superficial 
cervical  set  of  glands. 


168  SURGICAL  APPLIED  ANATOMY.     [Chap.  ix. 

Skin  of  face  and  neck  =  submaxillary,  parotid, 
and  superficial  cervical  glands. 

External  ear  =  superficial  cervical  glands. 

Lower  Up  =  submaxillary  and  suprahyoid  glands. 

Bticcal  cavity  =  submaxillary  glands  and  deep 
cervioal  glands  (upper  set). 

Gunis  of  lower  jaw  =  submaxillary  glands. 

Tongue. — Anterior  portion  =  suprahyoid  and  sub- 
maxillary  glands.  Posterior  portion  =  deep  cervical 
glands  (upper  set). 

Tonsils  and  palate  =  deep  cervical  glands  (upper 
set). 

Pharynx. — Upper  part  =  parotid  and  retro-plia- 
ryngeal  glands.  Lower  part  =  deep  cervical  glands 
(upper  set). 

Larynx,  orbit,  and  roof  of  mouth  =  deep  cervical 
glands  (upper  set). 

JVa#i7£/o,ssfe=retro-pharyngeal  glands,  deep  cervical 
glands  (upper  set).  Some  lymphatics  from  posterior 
part  of  the  fossje  enter  the  parotid  glands.* 

Branchial  fistulas. — Certain  congenital  fistula} 
are  sometimes  met  with  in  the  neck,  which  are  due  to 
partial  persistence  of  one  of  the  branchial  clefts. 
These  clefts  are  placed  in  the  foetus  between  the 
branchial  arches.  The  arches  are  usually  described 
as  five  in  number.  The  first  lays  the  foundation  for 
the  lower  jaw.  From  the  second  are  developed  the 
incus,  the  styloid  process,  the  stylo-hyoid  ligament 
and  lesser  cornu  of  the  hyoid  bone.  From  the  third 
is  formed  the  body  and  greater  cornu  of  the 
hyoid  bone,  while  the  fourth  and  fifth  take  part 
in  the  formation  of  the  soft  parts  of  the  neck 
below  the  hyoid  bone.  The  first  cleft  is  between 
the  first  and  second  arches.  "  The  cervical  branchial 
fistulse  appear  congenitally  as  very  fine  canals 
opening  into  minute  orifices  in  one  or  both  sides 
*  From  "Scrofula,  and  its  Gland  Diseases,"  by  the  Author. 


chap.  ix.j  THE  NECK.  1 69 

of  the  fore  part  of  the  neck,  and  leading  backwards 
and  inwards  or  backwards  and  upwards  towards 
the  pharynx  or  resophagus  "  (Paget).  Their  length  is 
about  1^  to  2£  inches,  and  their  diameter  varies  from 
that  of  a  bristle  to  that  of  an  ordinary  probe.  They 
usually  exist  about  the  line  of  the  third  or  fourth 
cleft,  and  are  most  often  met  with  just  above  the 
sterno-clavicular  joint.  Others  are  found  about  the 
level  of  the  top  of  the  thyroid  cartilage  at  the  anterior 
edge  of  the  sterno-mastoid  muscle.  About  some  of 
these  fistulse,  or  in  spots  where  they  commonly  open, 
flat  pieces  of  cartilage  may  be  found.  The  more 
prominent  of  these  have  been  termed  supernumerary 
auricles.  Certain  dermoid  cysts  of  the  neck  arise 
from  unobliterated  branchial  spaces,  and  it  would 
appear  also  that  certain  poly  cystic  congenital  tumours, 
occurring  as  one  form  of  "hydrocele  of  the  neck," 
may  be  developed  from  an  imperfectly  closed  cleft.  I 
have  elsewhere  detailed  the  dissection  of  one  of  these 
tumours  that  appeared  to  be  associated  witU  a  partially 
closed  second  branchial  cleft  (Path.  Soc.  Trans.,  1881). 


170 


CHAPTER    X 

THE   THORAX. 

1.  THE  thoracic  walls. — The  two  sides  of  the 
chest  are  seldom  symmetrical,  the  circumference  of 
the  right  side  being  usually  the  greater,  a  fact  that  is 
supposed  to  be  explained  by  the  unequal  use  of  the 
upper  limbs.  In  Pott's  disease,  involving  the  dorsal 
region,  when  the  spine  is  much  bent  forwards,  the 
thorax  becomes  greatly  deformed.  Its  antero-posterior 
diameter  is  increased,  the  sternum  protrudes,  and  may 
even,  be  bent  by  the  bending  of  the  spine,  the  ribs  are 
crushed  together,  and  the  body  may  be  so  shortened 
that  the  lower  ribs  overlap  the  iliac  crest. 

In  pigeon-breast!  deformity  the  sternum  and 
cartilages  are  rendered  protuberant,  so  that  the  antero- 
posterior  measurement  of  the  chest  is  much  increased, 
while  a  deep  sulcus  exists  on  either  side  along  the 
line  of  junction  of  the  ribs  and  their  cartilages.  It  is 
by  the  sinking  in  of  the  parietes  along  this  line  that 
the  protuberance  is  produced.  Shaw  gives  the  following 
explanation  of  this  deformity :  "  When  an  inspira- 
tion is  taken,  a  threatened  vacuum  is  created  within 
the  chest,  air  rushes  in  by  atmospheric  pressure,  and 
at  the  end  of  the  inspiration  the  balance  of  pressure 
without  the  chest  and  within  it  are  equalised.  If  in 
inspiration  there  is  an  impediment  to  the  entrance  of 
air,  the  atmospheric  pressure  upon  the  external  wall 
of  the  chest  must  produce  some  effect,  being  un- 
balanced by  a  bike  pressure  upon  the  inner  chest  wall. 
En  children,  and  especially  in  rickety  children,  the 


o-.ap.  x.j  THE  THORAX.  171 

thorax  is  very  pliable  and  elastic,  and  if  a  constant 
impediment  exists  to  the  entrance  of  air,  as  afforded, 
for  example,  by  greatly  enlarged  tonsils,  the  thoracic 
walls  may  yield  in  time  to  the  unbalanced  pressure 
brought  to  bear  upon  them  at  each  inspiration.  The 
weakest  part  of  the  thorax  is  along  the  costo-chondral 
line  on  either  side,  and  it  is  here  that  the  parietes 
yield  most  conspicuously  in  such  cases,  and  by  this 
yielding  the  deformity  is  produced." 

The  sternum* — The  upper  edge  of  the  sternum, 
corresponds  to  the  disc  between  the  second  and  third 
dorsal  vertebrae,  and  the  sterno- xiphoid  joint  to  the 
middle  of  the  ninth  dorsal.  In  the  foetus  at  full  term 
the  upper  edge  of  the  sternum  is  opposite  the  middle 
of  the  first  dorsal  vertebra  (Symington).  A  trans- 
verse ridge  may  be  felt  upon  its  anterior  surface  that 
corresponds  to  the  junction  of  the  manubrium  and 
gladiolus,  and  is  in  a  line  with  the  second  costal 
cartilages.  The  skin  over  the  sternal  region  is  the 
part  of  the  surface  most  frequently  the  seat  of  keloid. 
The  bone  is  rarely  fractured,  being  soft  and  spongy, 
and  supported  by  the  elastic  ribs  and  their  cartilages, 
as  by  a  series  of  springs.  In  the  old,  when  the  car- 
tilages are  ossified  and  the  chest  more  rigid,  the 
tendency  to  fractui-e  is  increased.  The  sternum  is 
most  often  found  fractured  in  connection  with  injuries 
to  the  spine,  although  it  may  be  broken  by  simple 
direct  violence.  The  bone  may  be  fractured  by 
violent  bending  of  the  spine  backwards,  and  by  abrupt 
bending  of  it  forwards.  In  the  former  instance  the 
lesion  is  probably  due  to  muscular  violence,  to  the 
abdominal  muscles  and  the  sterno-mastoid  pulling  one 
against  the  other.  In  the  latter  instance  the  lesion  is 
commonly  brought  about  by  the  violent  contact  of  the 
chin  with  the  bone.  In  all  instances  the  fracture  is 
usually  transverse,  and  most  often  occupies  the  line 
between  the  manubrium  and  the  gladiolus.  As  these 


172  SURGICAL  APPLIED  AWATOMY.       [Chap.  x. 

two  parts  of  the  bone  are  not  entirely  united  until 
middle  life,  and  are  often  not  united  at  all,  it  follows 
that  the  lesion  is  in  many  cases  a  dislocation  rather 
than  a  fracture.  The  manubrium  in  these  injuries 
generally  remains  in  situ,  while  the  gladiolus  with  the 
ribs  is  displaced  forwards  in  front  of  it.  Malgaigne 
cites  the  case  of  a  youth  who,  from  constant  bending 
at  his  work  as  a  watchmaker,  caused  the  second  piece 
of  the  sternum  to  glide  backwards  behind  the  manu- 
brium. Here,  probably,  the  connection  between  the 
two  bones  was  not  very  substantial. 

From  its  exposed  position  and  cancellous  structure, 
the  sternum  is  liable  to  many  affections,  such  as  caries 
and  gummatous  periostitis.  The  comparative  softness 
also  of  the  bone  is  such  that  it  has  been  penetrated  by 
a  knife  in  homicidal  wounds.  The  shape  and  position 
of  the  bone  have  also  been  altered  by  pressure,  as 
seen  sometimes  in  artisans  following  employments  re- 
quiring instruments,  etc.,  to  be  pressed  against  the 
chest. 

Certain  holes  may  appear  in  the  middle  of  the 
sternum,  and  through  them  mediastinal  abscesses  may 
escape,  and  surface  abscess  pass  deeply  into  the  thorax. 
In  the  case  of  E.  Groux,  the  bone  was  separated  verti- 
cally into  two  parts.  The  gap  could  be  opened  by 
muscular  effort,  and  the  heart  exposed  covered  only 
by  the  soft  parts.  The  sternum  has  been  trephined 
for  mediastinal  abscess,  and  for  paracentesis  in  peri- 
cardia! effusion,  and  it  has  been  proposed  also  to 
ligature  the  innominate  artery  through  a  trephine 
hole  in  the  upper  part  of  the  bone. 

The  ribs  are  placed  so  obliquely  that  the  anterior 
end  of  one  rib  is  on  a  level  with  the  posterior  end  of 
a  rib  some  way  below  it  in  numerical  order.  Thus 
the  first  rib  in  front  corresponds  to  the  fourth  rib 
behind,  the  second  to  the  sixth,  the  third  to  the 
seventh,  the  fourth  to  the  eighth,  the  fifth  to  the  ninth, 


Chap,  x.)  THE  THORAX.  173 

the  sixth  to  the  tenth,  and  the  seventh  to  the  eleventh. 
If  a  horizontal  line  be  drawn  round  the  body  at  the 
level  of  the  inferior  angle  of  the  scapula,  while  the 
arms  are  at  the  side,  the  line  would  cut  the  sternum 
in  front  at  the  attachment  of  the  sixth  cartilage,  would 
cut  the  fifth  rib  at  the  nipple  line,  and  the  eighth  rib 
at  the  vertebral  column.  The  second  rib  is  indicated 
by  the  transverse  ridge  on  the  sternum  already 
alluded  to.  The  lower  border  of  the  pectoralis  major 
leads  to  the  fifth  rib,  and  the  first  visible  serration  of 
the  serratus  magnus  corresponds  to  the  sixth.  The 
longest  rib  is  the  seventh,  the  shortest  the  first.  In 
breadth  the  bones  decrease  from  the  first  to  the 
twelfth.  The  most  oblique  rib  is  the  ninth. 

The  ribs  are  elastic  and  much  curved,  and  being 
attached  by  many  ligaments  behind  to  the  column, 
and  in  front  to  the  yielding  cartilages,  resist  injuries 
tending  to  produce  fracture  with  the  qualities 
possessed  by  a  spring.  A  rib  may  be  fractured  by 
indirect  violence,  as  by  a  wheel  passing  over  the  body 
when  lying  prostrate  on  the  back.  In  such  a  case 
the  force  tends  to  approximate  the  two  ends  of  the 
bone,  and  to  increase  its  curve.  When  it  breaks, 
therefore,  it  breaks  at  the  summit  of  its  principal 
curve,  i.e.  about  the  centre  of  the  bone.  The 
fragments  fracture  outwards,  and  the  pleura  stands 
no  risk  of  being  penetrated.  When  the  rib  is  broken 
by  direct  violence^  the  lesion  occurs  at  the  spot  en- 
countered by  the  force,  the  bone  fractures  inwards, 
the  curve  of  the  rib  tends  to  be  diminished  rather  than 
increased,  and  there  is  much  risk  of  the  fragments 
lacerating  the  pleura. 

Those  most  often  broken  are  the  sixth,  seventh, 
and  eighth,  they  being  under  ordinary  circumstances 
the  most  exposed.  The  rib  least  frequently  fractured 
is  the  first,  which  lies  under  cover  of  the  clavicle. 
Fractures  are  more  common  in  the  elderly  than  in 


^74  SURGICAL  APPLIED  ANATOMY.       rchap.x 

children,  owing  to  the  ossitication  of  the  cartilages 
that  takes  place  in  advancing  life.  When  a  rib  is 
fractured,  no  shortening  occurs,  the  bone  being  fixed 
both  in  front  and  behind,  while  vertical  displacement 
is  prevented  by  the  attachments  of  the  intercostal 
muscles.  Thus  no  obvious  deformity  is  produced  unless 
a  number  of  consecutive  ribs  are  the  subjects  of  frac- 
ture. These  bones  have  been  broken  by  muscular 
violence,  as  during  coughing,  and  in  violent  expulsive 
efforts  such  as  are  incident  to  labour.  In  such  in- 
stances the  ribs  are  probably  weakened  by  atrophy  or 
disease. 

In  many  instances  of  gun-shot  wound  the  curve 
of  the  rib  has  saved  the  patient's  life.  In  such  cases 
the  bullet  has  entered  behind  near  the  dorsal  spine, 
has  been  conducted  round  the  chest,  along  the  curve 
of  a  rib  beneath  the  skin,  and  has  escaped  again  near 
the  sternum.  This  property,  however,  of  the  ribs  for 
turning  bullets  refers  rather  to  the  days  of  round 
bullets,  and  not  to  modern  conical  projectiles. 

In  rickets  changes  take  place  at  the  point  of 
junction  of  the  ribs  and  cartilages  leading  to  bony 
elevations,  which  produce,  when  the  ribs  on  both  sides 
are  affected,  the  condition  known  as  the  "  rickety 
rosary." 

The  intercostal  spaces  are  wider  in  front 
than  behind,  and  between  the  upper  than  the  lower 
ribs.  The  widest  of  the  spaces  is  the  third,  then  the 
second,  then  the  first.  The  narrowest  spaces  are  the 
last  four.  The  first  five  spaces  are  wide  enough  to 
admit  the  whole  breadth  of  the  index  finger.  The 
spaces  are  widened  in  inspiration,  narrowed  in  expira- 
tion, and  can  be  increased  in  width  by  bending  the 
body  over  to  the  opposite  side. 

Paracewtesis  is  usually  performed  in  the  sixth 
or  seventh  space,  at  a  point  midway  between  the 
sternum  and  the  spine,  or  midway  between  the 


Chap.  x.i  THE  RIBS.  175 

anterior  aud  posterior  axillary  lines.  If  a  lower 
space  be  selected  there  is  danger  of  wounding  the 
diaphragm,  especially  upon  the  right  side.  If  the 
eighth  or  ninth  space  is  selected  the  incision  is  made 
just  external  to  the  line  of  the  angle  of  the  scapula. 
The  trochar  should  be  entered  during  inspiration,  the 
space  being  widened  thereby,  and  should  be  kept  as 
near  as  possible  to  the  lower  border  of  the  space,  so  as 
to  avoid  the  intercostal  vessels.  Tapping  of  the  chest 
through  any  space  posterior  to  the  angles  of  the  ribs 
is  not  practicable,  owing  to  the  thick  covering  of 
muscles  upon  the  thoracic  wall  in  this  place,  and  the 
fact  that  the  intercostal  artery,  having  a  more  hori- 
zontal course  than  the  corresponding  ribs,  crosses  the 
middle  of  this  part  of  the  space  obliquely.  Beyond 
the  angle  the  intercostal  vessels  lie  in  a  groove  on 
the  inferior  border  of  the  rib  forming  the  upper  boun- 
dary of  the  space.  The  vein  lies  immediately  above  the 
artery,  and  the  nerve  immediately  below  it.  In  the 
upper  four  or  five  spaces,  however,  the  nerve  is  at 
first  higher  than  the  artery. 

Owing  to  the  protection  it  derives  from  the  ribs 
and  the  intercostal  muscles,  it  happens  that  the  inter- 
costal artery  is  seldom  wounded,  and  when  wounded 
it  will  be  understood  that  considerable  difficulty  is 
experienced  in  securing  the  vessel  without  doing 
damage  to  the  pleura  and  adjacent  parts. 

Pus  may  readily  be  conducted  along  the  loose 
tissue  between  the  two  layers  of  intercostal  muscles. 
Thus,  in  suppuration  following  upon  disease  of  the 
vertebrae,  or  of  the  posterior  parts  of  the  ribs,  the  pus 
may  be  conducted  along  the  intercostal  spaces  to  the 
sternum,  and  may  thus  present  at  a  considerable 
distance  from  the  real  seat  of  the  disease. 

Removal  of  ribs.— In  order  to  obtain  a  free 
opening  into  the  pleural  cavity  a  portion  of  one  or 
even  two  ribs  may  be  excised. 


176  SURGICAL  APPLIED  ANATOMY.       [Chap,  x. 

In  some  cases  of  long-standing  empyema  with 
open  sinus  all  that  part  of  the  bony  wall  of  the  thorax 
which  corresponds  to  the  outer  boundary  of  the 
suppurating  cavity  is  removed  in  order  that  the  cavity 
may  collapse  and  be  in  a  position  to  close.  This  latter 
measure  is  known  as  Estlander's  operation,  or  thora- 
coplasty.  In  some  instances  portions  of  as  many  as 
nine  ribs  have  been  excised,  and  the  total  length  of 
bone  removed  has  reached  50  to  60  inches. 

In  removing  a  rib  the  bone  is  entirely  bared  of 
periosteum  with  the  rugine,  and  the  excision  is  extra- 
periosteal.  In  this  way  the  intercostal  vessels  are  not 
exposed,  and,  if  divided  subsequently,  can  be  readily 
secured  when  the  ribs  are  out  of  the  way. 

The  internal  mammary  artery  runs  parallel 
to  the  border  of  the  sternum,  and  about  half  an  inch 
from  it.  It  may  give  rise  to  rapidly  fatal  haemorrhage 
if  wounded.  The  vessel  may  readily  be  secured  in 
the  first  three  intercostal  spaces,  and  with  some  diffi- 
culty in  the  fourth  or  fifth  space.  It  is  most  easily 
reached  through  the  second  space,  and  cannot  be 
secured  through  any  space  below  the  fifth. 

The  female  breast  extends  from  the  third  to 
the  fifth  rib.  It  is  supported  by  the  superficial 
pectoral  fascia,  which  divides  into  two  layers  to 
enclose  it.  The  organ  is  made  up  of  an  accumulation 
of  alveolar  glands,  which  open  into  ducts  discharging 
at  the  nipple.  In  cases  where  during  lactation  the 
acini  are  engorged  with  milk,  the  outlines  of  the 
several  lobules  and  lobes  of  the  breast  are  rendered 
very  distinct.  The  size  of  the  breast  depends  usually 
rather  upon  a  deposit  of  fat  collected  about  the  organ 
and  distributed  among  its  lobules  than  upon  a 
development  of  true  gland  tissue.  A  considerable 
and  rapid  development  of  the  mammary  gland  tissue 
takes  place  at  puberty,  and  the  breast  remains  in 
its  most  perfect  anatomical  condition  during  the 


chap,  x.]  THE  BREAST.  177 

child-bearing  period  of  life.  After  the  cessation  of 
menstruation  the  glandular  tissue  atrophies,  although 
the  ducts  always  persist.  The  breast  is  thinner  at  the 
periphery  than  at  the  centre,  and  is  thinnest  about  a 
line  extending  from  the  nipple  to  the  sterno-clavicular 
joint.  Abscesses  situated  beneath  the  breast  not  un- 
frequently  make  their  way  through  the  gland  at  some 
point  along  this  line.  The  base  of  the  gland  is  flat,  and 
is  separated  from  the  pectoral  muscle  by  much  loose 
connective  tissue.  It  is  in  this  tissue  that  the  sub- 
mammary  abscess  forms.  There  is  sometimes  a  kind 
of  bursa  between  the  breast  and  the  muscle  which  has 
been  found  to  form  a  definite  hygroma  or  bursal  cyst 
(Velpeau).  Although  the  gland  is  but  loosely  con- 
nected with  the  pectoralis  major,  yet  it  moves  a  little 
with  that  muscle,  and  the  position  of  the  breast  can 
be  slightly  affected  by  the  movement  of  the  arm. 
It  is  important,  therefore,  that  the  arm  should  be 
kept  at  rest  in  inflammatory  affections  of  the  organ. 
In  cancer  the  gland  and  the  muscle  may  become 
intimately  adherent.  The  nipple  is  situated  over  the 
fourth  interspace,  about  three-quarters  of  an  inch 
from  the  junction  of  the  ribs  with  their  cartilages, 
and  some  four  inches  from  the  middle  line.  It 
contains  muscular  fibres,  by  means  of  which  it  can  be 
rendered  prominent  on  stimulation.  The  skin  about 
the  nipple  is  very  thin  and  sensitive,  and  is  often  the 
seat  of  painful  fissures  and  excoriations.  When  any 
contracting  growth,  such  as  scirrhus,  drags  upon  the 
ducts  of  the  gland,  the  nipple  becomes  retracted. 

Abscesses  of  the  breast  should  be  opened  by  in- 
cisions radiating  from  the  nipple,  so  as  to  avoid  un- 
necessary damage  to  the  mammary  ducts. 

The  breast  is  supplied  by  the  anterior  cutaneous 
branches  of  the  second,  third,  fourth,  and  fifth  inter- 
costal nerves,  and  by  the  lateral  branches  of  the  last 
three  of  those  nerves.  The  connections  of  these 
M— 4 


178  SURGICAL  APPLIED  ANATOMY.       [Chap. x. 

trunks  serve  to  explain  the  diffusion  of  the  pain 
that  is  sometimes  observed  in  painful  affections  of 
the  gland.  Thus  in  abscess  of  the  breast  pain  is 
often  felt  round  the  side  of  the  thorax  to  the  back, 
following  the  trunks  of  the  above-named  intercostal 
nerves ;  or  it  is  distributed  over  the  scapula  by  the 
cutaneous  branches  of  the  posterior  divisions  of  such 
dorsal  nerves  as  correspond  to  the  intercostal  trunks 
that  supply  the  breast ;  or  it  runs  down  the  arm 
along  the  intercosto-humeral  nerve  (a  branch  of  the 
second  intercostal),  or  shoots  up  the  neck,  probably, 
along  the  supra  clavicular  branch  from  the  cervical 
plexus,  which  communicates  with  the  same  intercostal 
trunk. 

The  gland  is  supplied  by  the  following  arteries, 
which  are  divided  in  excision  of  the  organ :  the 
second,  third,  fourth,  and  fifth  intercostal  branches 
of  the  internal  mammary  artery,  some  few  branches 
from  the  corresponding  intercostal  vessels,  the  long 
thoracic  artery,  and  the  external  mammary.  The 
majority  of  the  lymphatics  from  the  breast  proceed  to 
the  axilla.  Some  few  follow  the  mammary  branches 
of  the  internal  mammary  artery,  and  enter  the 
anterior  mediastinal  glands,  which  are  consequently 
often  found  enlarged  in  cancer  of  the  organ. 

As  the  chief  blood  supply  of  the  breast  conies 
from  the  axilla,  and  as  the  main  lymph  vessels  pro- 
ceed to  that  region,  it  follows  that  malignant  growths 
of  the  gland  tend  to  spread  towards  the  axilla  rather 
than  towards  the  middle  line. 

2.  The  thoracic  viscera. 

The  limy. — The  apex  of  the  lung  rises  in  the  neck 
from  one  to  two  inches  above  the  anterior  end  of  the 
first  rib.  The  anterior  edges  of  the  two  lungs  lie  be- 
hind the  sterno-clavicular  articulations,  pass  obliquely 
behind  the  manubrium,  and  meet  in  the  middle  line  at 
the  junction  of  the  manubrium  with  the  gladiolus.  The 


Chap,  x.i  THE  LUNG.  179 

edge  of  the  right  lung  then  continues  vertically  down- 
wards behind  the  middle  line  of  the  sternum  to  the 
sixth  chondro-sternal  articulation,  where  it  slopes  off 
along  the  line  of  the  sixth  rib.  The  edge  of  the  left 
lung  keeps  close  to  that  of  the  right  as  far  as  the  fourth 
chondro-sternal  articulation,  where  it  turns  off  to  the 
left,  following  a  line  drawn  from  the  fourth  cartilage 
to  the  apex  of  the  heart.  In  the  child,  owing  to  the 
thymus,  the  lungs  are  more  separated  in  front.  The 
two  edges  in  no  place  come  in  contact.  The  right 
reaches  the  middle  line,  but  the  left  only  reaches  the 
left  edge  of  the  sternum  (Symington).  The  lower 
border  of  the  lung  corresponds  to  a  slightly  convex 
line  drawn  round  the  chest  from  the  sixth  chondro- 
sternal  articulation  in  front  to  the  eleventh  dorsal 
spine  behind.  In  the  mammary  line  this  line  would 
correspond  to  the  sixth  rib,  in  the  mid-axillary  line 
to  the  ninth  rib,  and  in  a  line  continued  vertically 
downwards  from  the  inferior  angle  of  the  scapula  with 
the  tenth  rib.  The  pleura  extends  farther  down  than 
the  lung,  reaching  in  front  to  the  level  of  the  seventh 
chondro-sternal  union,  behind  to  the  eleventh  dorsal 
spine,  and  at  the  sides  to  a  point  some  two  and  a  half 
inches  above  the  lower  margin  of  the  thorax.  Thus* 
it  will  be  seen  that  the  pleura  and  diaphragm  may 
be  wounded  in  many  places  without  the  lungs  being 
involved.  The  lowest  part  of  the  pleura  is  only  sepa- 
rated from  the  kidneys  by  the  thin  layer  of  the 
diaphragm.  The  pleura  is  in  relation  with  the  eleventh 
rib  posteriorly,  but  not  with  the  twelfth.  It  extends 
lower  down  in  the  child  than  in  the  adult,  reaching 
the  costo-vertebral  joint  of  the  twelfth  rib. 

In  penetrating  wounds  involving  the  pleura,  aii 
may  enter  the  pleural  cavity,  producing  pneu mo- 
thorax,  and  this  air  may  be  subsequently  pressed  by 
the  respiratory  movements  into  the  subcutaneous 
tissues  through  the  wound  in  the  parietal  pleura,  and 


180  SURGICAL  APPLIED  ANATOMY,       [Chap. x. 

lead  to  surgical  emphysema.  The  two  layers  of  the 
pleura  are  so  intimately  in  contact  with  one  another 
in  the  normal  thorax  that  it  is  difficult  for  the  parietal 
pleui-a  to  be  wounded  without  injury  to  the  visceral 
layer.  In  wounds  of  the  lung  without  external  wound, 
as  when  that  organ  is  torn  by  a  fractured  rib,  the  air 
escapes  from  the  lung  into  the  pleura,  and  may  thence 
pass  into  the  subcutaneous  tissues  through  the  pleural 
wound,  thus  producing  both  pneunio  -  thorax  and 
emphysema. 

It  is  well  to  note  that  emphysema  may  occur 
about  certain  non-penetrating  wounds  of  the  thorax 
when  they  are  of  a  valvular  nature.  In  such  cases 
the  air  is  drawn  into  the  subcutaneous  tissues  during 
one  respiratory  movement,  and  is  forced  by  another 
into  the  cellular  tissue,  the  valvular  nature  of  the 
wound  preventing  its  escape  externally.  When  the 
pleural  "  cavity  "  is  opened,  the  lungs  become  more 
or  less  collapsed ;  yet  a  few  cases  have  been  recorded 
where  the  lung  has  protruded  at  the  time  of  the  acci- 
dent through  the  wound  in  the  parietes.  In  such  in- 
stances the  glottis  must  have  been  closed,  and  the  lung 
fully  distended  at' the  time  of  the  injury  ;  and  it  must 
be  further  assumed  that  the  viscus  was  practically  pro- 
truded before  air  could  enter  the  pleural  space.  It  is 
noticeable  that  these  recent  hernia3  are  most  common 
at  the  anterior  part  of  the  chest  where  the  lungs  are 
the  most  movable,  and  the  injui'ies  that  bring  them 
about  are  often  associated  with  violent  respiratory 
efforts  at  the  time  of  the  accident.  In  wounds  of  the 
lung  the  blood  may  escape  in  three  directions :  into 
the  tissue  of  the  organ  (pulmonary  apoplexy),  into  the 
bronchi  (causing  haemoptysis),  and  into  the  pleura 
(causing  hsemothorax).  In  some  instances  the  lung 
has  been  ruptured  without  wound  and  without  frac- 
ture to  the  ribs.  These  cases  are  difficult  to  interpret, 
and  probably  the  best  explanation  suggested  is  that 


Chap.  X.] 


THE  LUNG, 


181 


put  forward  by  M.  Gosselin.  This  surgeon  believes 
that  at  the  time  of  the  injury  the  lungs  are  suddenly 
filled  and  distended  with  air  by  a  full  inspiration,  and 
that  the  air,  prevented  from  escaping  by  occlusion  of  the 


Pig.  16.— Diagram  to  show  the  relations  of  the  Heart  to  the  Surface. 

(After  Eiidinger.) 
i,  Left  innominate  vein;  6,  right  innominate  vein;  c,  superior  vena  cava;  d, 

right  auricle  ;  e.  inferior  vena  cava;  /,  aorta ;  g,  pulmonary  artery  ;  7»,  right 

ventricle  ;  i,  left  ventricle ;  j,  left  auricle. 

larynx,  thus  becomes  pent  up  in  the  pulmonary  tissue, 
and  the  lung  not  being  able  to  recede  from  the  superin- 
cumbent pressure,  its  structure  necessarily  gives  way. 
Owing  to  the  fineness  of  its  capillaries,  and  to  the 
fact  that  all  venous  blood  returned  to  the  heart  must 
pass  through  the  lungs  before  it  can  reach  other  parts 
of  the  body,  it  follows  that  pysemic  and  other  secondary 


182  SURGICAL  APPLIED  ANATOMY.       [Chap.  x. 

deposits  are  more  commonly  met  with  in  the  lung 
than  in  any  other  of  the  viscera. 

Lung  cavities  resulting  from  tuberculosis,  gan- 
grene, or  bronchiectasis,  have  been  successfully  incised 
and  drained,  and  the  same  measure  has  been  applied 
to  hydrated  cysts  of  the  lung. 

The  trachea  divides  opposite  the  junction  of  the 
manubrium  and  gladiolus  in  front,  and  the  fourth 
dorsal  vertebra  behind  (Fig.  33).  In  the  newly  born 
the  trachea  bifurcates  opposite  the  third  vertebra 
(Symington). 

Certain  foreign  substances  that  have  been  drawn 
into  the  air  passages  have  shown  a  remarkable  facility 
for  escaping  through  the  parietes.  Thus  Mr.  Godlee 
records  the  case  of  a  child,  from  an  abscess  in  whose 
back  a  head  of  rye-grass  escaped,  that  had  found  its 
way  into  the  air  passages  forty-three  days  previously. 

The  heart.— The  relations  of  the  heart  to  the 
surface  are  as  follows.  Its  upper  limit  corresponds 
to  a  horizontal  line  crossing  the  sternum  about  the 
upper  border  of  the  third  cartilages.  Its  right  border 
to  a  curved  line  arching  from  the  third  right  cartilage 
at  the  sternum  to  the  seventh  right  chondro- sternal 
articulation,  and  reaching  about  1^  inches  from  the 
middle  line.  Its  lower  border  follows  a  line  from  the 
seventh  right  chondro-sternal  articulation  to  the  apex. 
Its  apex  is  opposite  the  fifth  interspace,  at  the  junction 
of  the  ribs  with  these  cartilages.  Its  base  is  opposite 
the  sixth,  seventh,  and  eighth  dorsal  vertebrae.  Its 
left  border  is  represented  by  an  arched  line  drawn  from 
the  apex  to  the  third  left  cartilage  at  the  sternum. 

The  orifice  of  the  pulmonary  artery  is  behind  the 
tipper  edge  of  the  third  left  cartilage  close  to  the 
sternum.  The  vessel  proceeds  upward  under  cover 
of  the  second  left  cartilage.  The  aortic  orifice  is  behind 
the  left  border  of  the  sternum  close  to  the  lower  edge 
of  the  third  cartilage.  The  trunk  ascends  behind  the 


Chap,  x.]  THE  HEART.  183 

second  cartilage  of  the  right  side,  and  would  be 
wounded  by  a  stab  through  that  cartilage  close  to 
the  sternum.  The  concavity  of  the  aortic  arch  corre- 
sponds to  the  point  between  the  first  and  second  pieces 
of  the  sternum.  The  auriculo-ventricular  orifices  are 
behind  the  sternum,  the  right  being  opposite  the  fourth 
spaces,  and  the  left  on  a  level  with  the  fourth  carti- 
lages. The  innominate  and  left  carotid  arteries  come 
off  at  a  spot  corresponding  to  the  middle  of  the  manu- 
brium,  and  run  behind  the  right  and  left  sterno-cla- 
vicular  joints  respectively.  The  superior  vena  cava 
would  be  wounded  by  a  knife  entering  either  the  first 
or  the  second  right  interspace  close  to  the  sternum. 
The  left  innominate  vein  lies  transversely  just  below 
the  upper  border  of  that  bone.  The  right  auricle 
would  be  wounded  in  stabs  passing  through  the  sternal 
ends  of  the  third,  fourth,  and  fifth  cartilages  on  the 
right  side,  or  through  the  corresponding  intercostal 
spaces  if  the  knife  be  kept  fairly  near  to  the  sternum. 
(See  Fig.  16,  which  shows  the  relations  of  the  heart 
and  great  vessels  as  given  by  Riidinger,  and  which 
differ  somewhat  from  the  above  account.) 

A  circle  with  a  diameter  of  two  inches,  and 
with  its  centre  midway  between  the  nipple  and  the 
end  of  the  gladiolus,  would  approximately  define 
that  part  of  the  heart  which  lies  immediately  behind 
the  chest  wall,  and  is  uncovered  by  lung  or  pleura 
(Latham). 

Wounds  of  the  heart  most  frequently  involve  the 
right  ventricle,  that  segment  of  the  heart  being  the 
part  most  exposed  anteriorly.  Next  in  frequency  is 
the  left  ventricle  wounded,  and  then  the  I'ight  auricle. 
Other  things  being  equal,  a  wound  of  the  ventricle  is 
less  rapidly  fatal  than  is  a  woiind  of  the  auricle,  owing 
to  the  thickness  of  the  ventricular  wall,  and  to  its 
capacity  for  contracting  and  preventing  the  escape  of 
blood.  Death  in  cases  of  wound  of  the  heart  would 


184  SURGICAL  APPLIED  ANATOMY.      [Chap.  x. 

appear  in  a  great  number  of  cases  to  be  due  to  an 
impression  upon  the  nervous  centres  rather  than  upon 
actual  haemorrhage.  Many  instances  have  been 
recorded  to  show  that  the  heart  may  be  very  tolerant 
of  foreign  bodies  in  its  substance.  Thus  a  man  lived 
for  twenty  days  with  a  skewer  traversing  the  heart 
from  side  to  side  (Ferrus).  In  another  case  a  lunatic 
pushed  an  iron  rod,  over  six  inches  in  length,  into  his 
chest,  until  it  disappeared  from  view,  although  it 
could  be  felt  beneath  the  skin  receiving  pulsation 
from  the  heart.  He  died  a  year  following,  and  the 
metal  was  found  to  have  pierced  not  only  the  lungs, 
but  also  the  ventricular  cavities  (Tillaux).  A  propos 
of  chest  wounds,  Velpeau  cites  the  case  of  a  man  in 
whose  thorax  was  found  a  part  of  a  foil  that  entirely 
transfixed  the  chest  from  ribs  to  spine,  and  that  had 
been  introduced  fifteen  years  before  death.  In  the 
museum  of  the  Royal  College  of  Surgeons  is  the 
shaft  of  a  cart  that  had  been  forced  through  the  ribs 
on  the  left  side,  had  passed  entirely  through  the  chest, 
and  had  come  out  through  the  ribs  on  the  right  side. 
The  patient  had  lived  ten  years. 

Paracentesis  of  the  pericardium  has  been 
performed  through  the  fourth  or  fifth  spaces  on  the 
left  side  close  to  the  sternum,  care  being  taken  to 
avoid  the  internal  mammary  artery.  The  operation 
has  also  been  performed  through  a  trephine  hole 
made  in  the  middle  line  of  the  sternum. 

The  mediastina.— Abscess  in  the  anterior 
mediastinum  may  have  developed  in  situ,  or  may 
have  spread  down  from  the  neck.  In  like  manner 
posterior  mediastinal  abscesses  may  arise  from  diseases 
of  the  adjacent  spine,  or  lymphatic  glands,  or  may  be 
due  to  the  spreading  downwards  of  a  retro-pharyngeal 
or  retro-oesophageal  collection  of  matter. 

The  azygos  veins,  commencing  as  they  do  below 
in  the  lumbar  veins,  and  having  more  or  less  direct 


chap,  x.j  THE  MEDIASTINA.  185 

communications  with  the  common  iliac,  renal,  and 
other  tributaries  to  the  vena  cava,  are  able  to  a  great 
extent  to  carry  on  the  venous  circulation  in  cases  of 
obstruction  of  the  main  trunk. 

These  veins  are  apt  to  be  pressed  upon  by  tumours 
(such  as  enlarged  gland  masses)  developed  in  the 
posterior  mediastinum,  and  to  produce  in  consequence 
some  oedema  of  the  chest  walls  by  engorgement  of 
those  intercostal  veins  that  they  receive.  Tumours 
growing  in  the  posterior  mediastinum  may  cause 
trouble  by  pressing  upon  the  trachea  or  gullet,  or  by 
disturbing  the  vagus  nerve  or  the  cord  of  the  sym- 
pathetic (Figs.  33  and  35). 

Krabbel  reports  a  case  of  fracture  of  the  ninth 
dorsal  vertebra  associated  with  rupture  of  the  thoracic 
duct.  The  patient  died  in  a  few  days,  and  the  right 
pleura  was  found  to  contain  more  than  a  gallon  of 
pure  chyle. 


i86 


Part 


THE  UPPER  EXTREMITY. 


CHAPTER  XI. 

THE    REGION    OF    THE    SHOULDER, 

A  STUDY  of  the  region  of  the  shoulder  comprises 
the  clavicle,  the  scapula,  the  upper  end  of  the  humerus, 
and  the  soft  parts  that  surround  them,  together  with 
the  shoulder  joint  and  axilla. 

Surface  anatomy. — The  clavicle,  acromion  pro- 
cess, and  scapular  spine  are  all  subcutaneous,  and  can 
be  readily  felt.  In  the  upright  position,  when  the 
arm  hangs  by  the  side,  the  clavicle  is,  as  a  rule,  not 
quite  horizontal.  In  well-developed  subjects  it  inclines 
a  little  upwards  at  its  outer  end.*  In  the  recumbent 
posture,  the  weight  of  the  limb  being  taken  off,  the 
outer  end  rises  still  higher  above  the  sternal  extremity. 
The  degree  of  the  elevation  can  be  best  estimated  by 
a  study  of  frozen  sections.  Thus,  in  making  horizontal 
sections  of  the  body,  layer  by  layer,  from  above  down- 
wards, Braune  found  that  by  the  time  the  sterno- 
clavicular  articulation  was  reached,  the  head  of  the 
humerus  would  be  cut  across  in  the  lateral  part  of 
the  section  (Fig.  17). 

The  deltoid  tubercle  of  the  clavicle  may,  if  large, 
be  felt  through  the  skin,  and  be  mistaken  for  an 
exostosis.  The  acromio-clavicular  joint  lies  in  the 
plane  of  a  vertical  line  passing  up  the  middle  of  the 

*  In  some  women,  in  the  feeble,  and  in  some  narrow-shoul- 
dered men,  the  clavicle  may  be  horizontal,  or  its  outer  end  may 
incline  downwards. 


chap,  xi.]        REGION  OF  THE  SHOULDEP..  187 

front  of  the  arm.  A  prominence  is  sometimes  felt 
about  this  joint  in  place  of  the  level  surface  that  it 
should  present.  This  is  due  to  an  enlargement  of  the 
end  of  the  clavicle,  or  to  a  thickening  of  the  fibro- 
cartilage  sometimes  found  in  the  joint.  In  many 
cases  it  has  appeared  to  me  to  be  due  to  a  trifling 
luxation  upwards  of  the  clavicle  depending  upon  some 
stretching  of  the  ligaments.  It  is  certain  that  the 
dry  bone  seldom  shows  such  an  enlargement  as  to 
account  for  this  very  common  prominence  at  the 
acromial  articulation.  The  sternal  end  of  the  clavicle 
is  also,  in  muscular  subjects,  often  large  and  unduly 
prominent,  and  sufficiently  conspicuous  to  suggest  a 
lesion  of  the  bone  or  joint  when  none  exists. 

The  roundness  and  prominence  of  the  point  of  the 
shoulder  depend  upon  the  development  of  the  deltoid 
and  the  position  of  the  upper  end  of  the  humerus. 
The  deltoid  hangs  like  a  curtain  from  the  shoulder 
girdle,  and  is  bulged  out,  as  it  were,  by  the  bone 
that  it  covers.  If  the  head  of  the  humerus,  there- 
fore, be  diminished  in  bulk,  as  in  some  impacted 
fractures  about  the  anatomical  neck,  or  be  removed 
from  the  glenoid  cavity,  as  in  dislocations,  the 
deltoid  becomes  more  or  less  flattened,  and  the  acro- 
mion  proportionately  prominent.  The  part  of  the 
humerus  felt  beneath  the  deltoid  is  not  the  head, 
but  the  tuberosities,  the  greater  tuberosity  externally, 
the  lesser  in  front.  A  considerable  portion  of  the 
head  of  the  bone  can  be  felt  by  the  fingers  placed 
high  up  in  the  axilla,  the  arm  being  forcibly  abducted 
so  as  to  bring  the  head  in  contact  with  the  lower 
part  of  the  capsule.  The  head  of  the  humerus  faces 
very  much  in  the  direction  of  the  internal  condyle. 
As  this  relation,  of  course,  holds  good  in  every 
position  of  the  bone,  it  is  of  value  in  examining 
injuries  about  the  shoulder,  and  in  reducing  disloca- 
tions by  manipulation,  the  condyle  being  used  as 


1 88  SURGICAL  APPLIED  ANATOMY.     [Chap.  xi. 

an  index  to  the  position  of  the  upper  end  of  the 
bone. 

In  thin  subjects  the  outline  and  borders  of  the 
scapula  can  be  more  or  less  distinctly  made  out,  but 
in  fat  and  muscular  subjects  all  parts  of  the  bone, 
except  the  spine  and  acromion,  are  difficult  of  access 
in  the  ordinary  positions  of  the  limb.  To  bring  out 
the  superior  angle  and  vertebral  border  of  the  bone, 
the  hand  of  the  subject  should  be  carried  as  far  as  pos- 
sible over  the  opposite  shoulder.  To  bring  out  the 
inferior  angle  and  axillary  border,  the  fore-arm  should 
be  placed  behind  the  back.  The  angle  formed  at 
the  point  of  junction  of  the  spine  of  the  scapula 
and  the  acromion,  is  the  best  point  from  which  to 
take  measurement  of  the  arm,  the  tape  being  carried 
down  to  the  external  condyle  of  the  humerus. 

When  the  arm  hangs  from  the  side  with  the  palm 
of  the  hand  directed  forwards,  the  acromion,  external 
condyle,  and  styloid  process  of  the  radius,  all  lie  in  the 
same  line.  The  groove  between  the  pectoralis  major 
and  deltoid  muscles  is  usually  to  be  made  out.  In  it 
run  the  cephalic  vein  and  a  large  branch  of  the  acromio- 
thoracic  artery.  Near  the  groove,  and  a  little  below 
the  clavicle,  the  coracoid  process  may  be  felt.  The 
process,  however,  does  not  actually  present  in  the 
interval  between  the  two  muscles,  but  is  covered  by  the 
innermost  fibres  of  the  deltoid.  The  position  of  the 
coraco-acromial  ligament  may  be  defined,  and  a  knife, 
thrust  through  the  middle  of  it,  should  strike  the 
biceps  tendon  and  open  the  shoulder  joint. 

When  the  arm  hangs  at  the  side  with  the  palm 
forwards,  the  bicipital  groove  may  possibly  be  defined. 
It  looks  directly  forwards. 

Just  below  the  clavicle  is  a  depression,  the  sub- 
clavicular  fossa,  which  varies  considerably  in  depth 
in  different  subjects.  It  is  obliterated  in  subcoracoid 
dislocations  of  the  humerus,  in  fractures  of  the  clavicle 


chap,  xi.2        REGION  OF  THE  SHOULDER.  189 

with  displacement,  by  many  axillary  growths,  and  by 
some  inflammations  of  the  upper  part  of  the  thoracic 
wall.  In  subclavicular,  or  intracoracoid  dislocation, 
the  fossa  is  replaced  by  an  eminence.  In  this  region, 
at  a  spot  to  the  inner  side  of  the  coracoid  process, 
and  corresponding  nearly  to  the  middle  of  the  clavicle, 
the  pulsations  of  the  axillary  artery  can  be  felt  on 
deep  pressure,  and  the  vessel  be  compressed  against  the 
second  rib.  Just  below  the  clavicle  the  interspace 
between  the  sternal  and  clavicular  portions  of  the 
pectoralis  major  can  often  be  made  out. 

The  anterior  and  posterior  borders  of  the  axilla 
are  very  distinct.  The  anterior  border  formed  by  the 
lower  edge  of  the  pectoralis  major  follows  the  line  of 
the  fifth  rib.  The  depression  of  the  armpit  varies, 
other  things  being  equal,  with  the  position  of  the 
upper  limb.  It  is  most  deep  when  the  arm  is  raised 
from  the  side  at  about  an  angle  of  45°,  and  when  the 
muscles  forming  the  borders  of  the  space  are  in  a 
state  of  contraction.  As  the  arm  is  raised  above  the 
horizontal  line  the  depression  becomes  shallower,  the 
head  of  the  bone  projects  into  the  space  and  more 
or  less  obliterates  it,  while  the  width  of  the  fossa  is 
encroached  upon  by  the  approximation  of  the  anterior 
and  posterior  folds.  The  coraco-brachialis  muscle 
itself  forms  a  distinct  projection  along  the  humeral 
side  of  the  axilla  when  the  arm  is  raised  to  a  right 
angle  with  the  body.  If  the  arm  be  brought  nearly 
close  to  the  side,  the  surgeon's  hand  can  be  thrust 
well  up  into  the  axilla,  and  the  thoracic  wall  explored 
as  high  up  as  the  third  rib. 

The  axillary  glands  cannot  be  felt  when  they  are 
in  a  normal  condition. 

The  direction  of  the  axillary  artery,  when  the  arm 
is  raised  from  the  side,  is  represented  by  a  line  drawn 
from  about  the  middle  of  the  clavicle  to  the  humerus 
at  the  inner  side  of  the  coraco-brachialis.  A  line 


190  SURGICAL  APPLIED  ANATOMY.      [Chap. xi. 

drawn  from  the  third  rib  near  its  cartilage  to  the  tip 
of  the  coracoid  process  indicates  the  upper  border  of 
the  pectoralis  minor,  and  the  spot  where  this  line 
crosses  the  line  of  the  axillary  artery  points  out  the 
position  of  the  acromio-thoracic  artery.  A  line  drawn 
from  the  fifth  rib  near  its  cartilage  to  the  tip  of  the 
coracoid  process  indicates  the  lower  border  of  the 
pectoralis  minor,  and  the  position  of  the  long  thoracic 
artery  which  runs  along  that  border.  The  line  of  the 
subscapular  artery  corresponds  to  the  lower  border  of 
the  subscapularis  muscle  along  which  it  runs,  but  the 
position  of  this  border  can  only  be  approximately 
indicated  on  the  living  or  undissected  subject. 

The  circumflex  nerve  and  posterior  circumflex 
artery  cross  the  humerus  in  a  horizontal  line  that  is 
about  a  finger's  breadth  above  the  centre  of  the  vertical 
axis  of  the  deltoid  muscle.  This  point  is  of  importance 
in  cases  of  supposed  contusion  of  the  nerve.  The 
dorsalis  scapulae  artery  crosses  the  axillary  border  of 
the  scapula  at  a  point  corresponding  to  the  centre  of 
the  vertical  axis  of  the  deltoid  muscle.  These  various 
indications  of  the  positions  of  the  main  branches  of 
the  axillary  artery  are  made  while  the  arm  hangs  in 
its  natural  position  at  the  side. 

The  clavicle. — The  skin  over  the  clavicle  is 
loosely  attached,  and  is  easily  displaced  about  the 
bone.  This  circumstance  may  serve  to  explain  why 
the  skin  so  often  escapes  actual  wound  in  contusions 
of.  the  clavicular  region,  and  in  part  explains  the 
infrequency  of  penetration  of  the  integument  in 
fractures  of  the  clavicle.  The  position  of  the  supra- 
clavicular  nerves  in  front  of  the  bone  renders  them 
very  liable  to  contusion,  and  accounts  for  the  unusual 
amount  of  pain  that  is  said  to  sometimes  follow 
blows  over  the  collar  bone.  Tillaux  believes  that  the 
severe  pain  that  in  rare  cases  persists  after  fracture  of 
the  clavicle  is  due  to  the  implication  of  these  nerves 


chap,  xi.]  THE  CLAVICLE.  191 

in  the  callus  formed.  The  three  nerves  that  cross  the 
clavicle  are  branches  of  the  third  and  fourth  cervical 
nerves,  and  it  is  well  to  note  that  pain  over  the  collar 
bone  is  sometimes  a  marked  feature  in  disease  of  the 
upper  cervical  spine.  This  symptom  is  then  due 
to  irritation  of  these  nerves  at  their  points  of  exit 
from  the  spinal  canal. 

Beneath  the  clavicle  the  great  vessels  and  the 
great  nerve-cords  lie  upon  the  first  rib.  The  vein  is 
the  most  internal,  and  occupies  the  acute  angle 
between  the  collar  bone  and  the  first  rib.  It  will  be 
seen  that  growths  from  the  bone  may  readily  press 
upon  these  important  structures,  and  that  the  vein, 
from  its  position,  as  well  as  from  the  slighter  resis- 
tance that  it  offers,  is  likely  to  be  the  first  to  be 
compressed.  These  structures  have  also  been  wounded 
by  fragments  of  bone  in  fracture  of  the  clavicle.  Fortu- 
nately, between  the  clavicle  and  these  large  nerves 
and  vessels  the  subclavius  muscle  is  interposed.  This 
muscle  is  closely  attached  to  the  under  surface  of  the 
bone,  is  enveloped  in  a  dense  fascia,  and  forms  one  of 
the  chief  protections  to  the  vessels  in  cases  of  fracture. 
This  interposing  pad  of  muscle  is  also  of  great  service 
in  resection  operations,  as  can  be  well  understood. 
Braune  states  that  by  pressing  the  clavicle  against  the 
first  rib  in  the  dead  body  a  stream  of  injection  in  the 
thoi'acic  duct  can,  in  some  cases,  be  entirely  arrested. 
Behind  the  clavicle  the  following  structures  may  be 
noted  :  The  brachio-cephalic,  subclavian,  and  external 
jugular  veins,  the  subclavian,  suprascapular,  and  in- 
ternal mammary  arteries,  the  cords  of  the  brachial 
plexus,  the  phrenic  nerve  and  nerve  of  Bell,  the  thoracic 
duct,  the  omo-hyoid,  scalene,  sterno-hyoid  and  sterno- 
thyroid  muscles,  the  apex  of  the  lung.  The  sternal 
end  of  the  bone  is  not  far  removed  from  the  innominate, 
or  left  carotid  artery,  the  vagus  and  recurrent  nerves, 
the  trachea,  and  the  esophagus. 


192 


SURGICAL  APPLIED  ANATOMY.      [Chap.  XL 


These  relations  of  the  clavicle  are  given  to  show 
the  clangers  in  the  way  of  partial  or  complete 
resections  of  the  bone.  The  difficulties  and  risks 
of  the  operation  increase  as  one  progresses  from  the 


Fig.  17. — Horizontal  Section  of  the  Body  just  below  the  Upper  Border 

of  the  Manubrium  (Braune). 
a,  Ma 


mubrium  ;  6,  head  of  humerus ;  c,  clavicle  ;  d,  first  rib  :  e,  second  rib  ;  /,  third 
orsal  vertebra;  a,  spine  of  second  dorsal ;  h.  pectoralis  major;  i,  deltoid  ; 


acromial  to  the  sternal  end.  Resection  of  the  acromial 
third  of  the  bone  is  comparatively  easy,  but  resection 
of  the  sternal  portion  is  most  difficult  and  dangerous. 
The  entire  clavicle  has  been  removed  with  success, 
and  the  operation  has  been  followed  by  less  impair- 
ment of  the  arm  movements  than  would  be  imagined. 
The  clavicle  forms  the  sole  direct  bony  connection 
between  the  upper  limb  and  the  trunk,  and  in  severe 


chap. XL]  THE  CLAVICLE.  193 

accidents,  this  connection  being  broken  through,  it  is 
possible  for  the  extremity  to  be  torn  off  entire.  Thus 
Billroth  reports  the  case  of  a  boy  aged  fourteen, 
whose  right  arm,  with  the  scapula  and  clavicle,  was  so 
torn  from  the  trunk  by  a  machine  accident,  that  it  was 
only  attached  by  a  strip  of  skin  two  inches  wide.  Other 
like  cases  of  avulsion  of  the  limb  have  been  reported. 
Fractures  of  clavicle. — The  clavicle  is  more 
frequently  broken  than  is  any  other  single  bone  in 
the  body.  This  frequency  is  explained  by  the  fact 
that  the  bone  is  very  superficial,  is  in  a  part  exposed 
to  injury,  is  slender  and  contains  much  compact 
tissue,  is  ossified  at  a  very  early  period  of  life,  and 
above  all  receives  a  large  part  of  all  shocks  communi- 
cated to  the  upper  extremity.  The  common  fracture, 
that  due  to  indirect  violence,  is  oblique,  and  very 
constant  in  its  position,  viz.  at  the  outer  end  of  the 
middle  third  of  the  bone.  The  bone  breaks  at  this 
spot  for  the  following  reasons.  It  is  here  that  the 
clavicle  is  the  most  slender ;  it  is  here  that  the 
two  curves  of  the  bone  meet ;  it  is  here  that  a  very 
fixed  part  of  the  bone,  viz.  the  outer  third,  joins 
with  a  more  movable  portion.  The  position  of  the 
coraco-clavicular  ligaments  is  no  doubt  of  the  greatest 
import  in  localising  the  fracture  in  this  position,  since 
a  clavicle  experimentally  subjected  to  longitudinal 
compression  does  not  break  at  this  spot  (Bennett). 
The  displacement  that  occurs  is  as  follows.  The  inner 
fragment  remains  unchanged  in  position,  or  its  outer 
end  is  drawn  a  little  upwards  by  the  sterno-mastoid. 
It  will  be  seen  that  any  action  of  this  muscle  would 
he  resisted  by  the  pectoralis  major  and  the  rhomboid 
ligament.  The  outer  fragment  undergoes  a  threefold 
displacement.  (1)  It  is  carried  directly  downwards. 
This  is  effected  mainly  by  the  weight  of  the  limb 
aided  by  the  pectoralis  minor,  the  lower  fibres  of  the 
pectoralis  major,  and  the  latissimus  dorsi.  Since  the 

11—4 


194  SURGICAL  APPLIED  AM  ATOMY.     [Chap.  xi. 

line  of  action  of  the  trapezius  muscle  is  altered  by  the 
fracture,  that  muscle  is  no  longer  able  to  keep  the 
shoulder  up,  and  its  altered  action  therefore  contri- 
butes to  the  downward  displacement.  (2)  It  is  carried 
directly  inwards  by  the  muscles  that  pass  from  the 
trunk  to  the  shoulder,  viz.  the  trapezius,  the  levator 
anguli  scapuhe,  the  rhomboids,  the  latissimus  dorsi,  and 
especially  by  the  pectorals.  To  these  may  be  added 
the  subclavius.  (3)  The  fragment  is  rotated  in  such  a 
way  that  the  outer  end  projects  forwards  and  the 
inner  end  back.  This  rotation  is  brought  about 
mainly  by  the  two  pectoi-als  assisted  prominently  by 
the  serratus  magnus.  The  normal  action  of  this  latter 
muscle  is  to  carry  the  scapula  forwards,  and  the 
clavicle,  acting  as  a  kind  of  outrigger  to  keep  the 
upper  limb  at  a  proper  distance  from  the  trunk,  moves 
forwards  at  the  same  time  and  keeps  the  scapula 
direct.  When  this  outrigger  is  broken  the  serratus 
can  no  longer  carry  the  scapula  directly  forwards. 
The  bone  tends  to  turn  towards  the  trunk,  and  the 
point  of  the  shoulder  is  therefore  seen  to  move  inwards 
as  well  as  forwards.  The  fragments  in  this  fracture 
must  consequently  overlap,  and  as  the  displacement  is 
difficult  to  remedy,  it  follows  that  in  no  bone  save  tha 
femur  is  shortening  so  uniformly  left  as  after  an 
oblique  fracture  of  the  clavicle.  The  degree  of 
shortening  very  seldom  exceeds  one  inch.  The 
deformity  associated  with  this  fracture  is  well 
remedied  when  the  patient  assumes  the  recumbent 
position.  In  this  posture,  the  weight  of  the  limb 
being  taken  off,  the  downward  displacement  is  at 
once  remedied.  The  point  of  the  shoulder  falling 
back  also  tends  to  relieve  in  part  the  inward  displace- 
ment, and  the  rotation  of  the  outer  fragment  forwards. 
It  is  through  the  scapula,  however,  that  these  two 
latter  displacements  are  in  the  main  removed.  In 
the  recumbent  posture  the  scapula  is  pressed  dosr-ly 


ciw.  xi. j  THE  CLAVICLE.  195 

against  the  thorax,  with  the  result  that  its  outer 
extremity  (and  with  it,  of  course,  the  outer  fragment 
of  the  clavicle)  is  dragged  outwards  and  backwards. 
Some  surgeons,  recognising  this  important  action  of  the 
scapula  in  remedying  the  displacement  in  these  cases, 
strap  the  scapula  firmly  against  the  trunk,  while  at 
the  same  time  they  elevate  the  arm. 

Fractures  due  to  direct  violence  are  usually 
transverse,  and  may  be  at  any  part  of  the  bone. 
When  about  the  middle  third  they  present  the 
displacement  just  described.  When  the  fracture  is 
between  the  conoid  and  trapezoid  ligaments  no  dis- 
placement is  possible.  When  beyond  these  ligaments 
the  outer  end  of  the  outer  fragment  is  carried  forwards 
by  the  pectorals  and  serratus,  and  its  inner  end  is 
a  little  drawn  up  by  the  trapezius.  In  this  fracture 
there  is  no  general  displacement  downwards  of  the 
outer  fragment,  since  it  cannot  move  in  that  direction 
unless  the  scapula  go  with  it,  and  the  scapula  remains 
fixed  by  the  coraco-clavicular  ligaments  to  the  inner 
fragment  of  the  clavicle. 

The  clavicle  may  be  broken  by  muscular  violence 
alone.  Polaillon,  from  a  careful  analysis  of  the 
reported  cases,  concludes  that  the  muscles  that  break 
the  bone  are  the  deltoid  and  clavicular  part  of  the 
great  pectoral.  In  no  case  does  the  fracture  appear 
to  have  been  produced  by  the  sterno-mastoid  muscle. 
The  commonest  movements  producing  fracture  appear 
to  be  violent  movements  of  the  limb  forwards  and 
inwards,  or  upwards.  These  fractures  are  usually 
about  the  middle  of  the  bone,  and  show  no  displace- 
ment other  than  that  of  both  fragments  forwards,  i.e. 
in  the  direction  of  the  fibres  of  the  two  muscles  first 
named. 

The  clavicle  is  more  frequently  the  seat  of 
green-stick  fracture  than  is  any  other  bone  in  the 
body.  Indeed,  one-half  of  the  cases  of  broken  collar 


196  SURGICAL  APPLIED  ANATOMY.     [Chap.  xi. 

bone  occur  before  the  age  of  five  years.  This  is  ex- 
plained by  the  fact  that  the  bone  is  ossified  at  a  very 
early  period,  and  is  in  a  breakable  condition  at  a  time 
when  most  of  the  other  long  bones  still  present  much 
unossified  cartilage  in  their  parts.  Moreover,  the 
periosteum  of  the  clavicle  is  unduly  thick,  and  not 
very  closely  attached  to  the  bone,  circumstances  that 
greatly  favour  subperiosteal  fracture. 

A  reference  to  the  relations  of  the  bone  will 
show  that  important  structures  may  be  wounded  in 
severe  fractures  associated  with  much  displacement 
and  with  sharp  fragments.  Several  cases  are  reported 
of  paralysis  of  the  upper  limb  (as  a  rule  incomplete) 
following  upon  fracture  of  this  bone.  In  some  cases 
this  symptom  was  due  to  actual  compression,  or 
tearing  of  some  of  the  great  nerve  cords  by  the  dis- 
placed fragments.  In  other  cases  the  nerve  injury, 
while  due  to  the  original  accident,  was  yet  indepen- 
dent of  the  broken  clavicle.  Cases  are  reported  of 
wound  of  the  subclavian  artery,  of  the  subclavian  vein, 
of  the  internal  jugular  vein,  and  of  the  acromio-thoracic 
artery.  In  several  instances  the  fracture  has  been 
associated  with  wound  of -the  lung,  with  or  without  a 
fracture  of  the  upper  ribs. 

The  clavicle  begins  to  ossify  before  any  bone  in 
the  body.  At  birth  the  entire  shaft  is  bony,  the  two 
ends  being  still  cartilaginous.  The  bone  has  one 
epiphysis  for  its  sternal  end  that  appears  between  the 
eighteenth  and  twentieth  year,  and  joins  the  shaft 
about  twenty-five.  It  is  a  mere  shell,  is  closely 
surrounded  by  the  ligaments  of  the  sternal  joint,  and 
cannot,  therefore,  be  well  separated  by  accident.* 

Steruo-clavicular  joint. — A  though     this    is 

*  Mr.  Heath  (Lancet,  Nov.  18,  1882)  reports  a  case  which  is 
probably  unique.  It  concerns  a  lad,  aged  14,  who,  when  in  the 
act  of  bowling  at  cricket,  tore  the  clavicle  away  from  its  epiphyseal 
cartilage,  which  remained  in  situ.  The  muscle  producing  the 
accident  was  apparently  the  pectoralis  major. 


Chap,  xi.]     THE  STERNO-CLAVICULAR  JOINT.          197 

the  only  articulation  that  directly  connects  the  upper 
limb  with  the  trunk,  yet  it  is  possessed  of  such  con- 
siderable strength  that  luxation  at  the  joint  is  com- 
paratively rare.  The  amount  of  movement  in  the 
joint  depends  to  a  great  extent  upon  the  lack  of 
adaptability  between  the  facet  on  the  sternum  and 
the  sternal  end  of  the  clavicle.  The  disproportion 
between  these  parts  is  maintained  by  the  inter- 
articular  cartilage,  which  reproduces  only  the  outline 
of  the  clavicular  surface.  The  cavity  of  the  joint  is 
V-shaped,  since  the  clavicle  only  touches  the  socket 
at  its  inferior  angle  when  the  arm  hangs  by  the  side. 
When  the  arm  is  elevated,  however,  the  two  bones  are 
brought  in  more  immediate  contact,  and  the  joint 
cavity  becomes  a  mere  slit.  Thus,  in  disease  of  this 
articulation  it  will  be  found  that  of  all  movements  of 
the  joint  the  movement  of  the  limb  upwards  is  the 
most  constant  in  producing  pain.  The  joint  is  sup- 
plied by  the  suprasternal  nerve. 

The  movements  permitted  at  this  joint  are 
limited,  owing  to  the  anterior  and  posterior  sterno- 
clavicular  ligaments  being  moderately  tense  in  all 
positions  of  the  clavicle.  Movement  forwards  of  the 
clavicle  on  the  sternum  is  checked  by  the  posterior 
ligament,  and  resisted  by  the  anterior  ligament.  This 
latter  ligament  is  more  lax  and  less  substantial  than 
is  the  posterior  band.  Its  weakness  serves  in  part 
to  explain  the  frequency  of  the  dislocation  forwards. 

Movement  of  the  clavicle  backwards  on  the 
sternum  is  checked  by  the  anterior  ligament,  while 
the  passage  of  the  head  of  the  bone  is  resisted  by  the 
powerful  posterior  band.  The  movement  is  also 
opposed  by  the  rhomboid  ligament.  To  produce, 
therefore,  a  dislocation  backwards  considerable  force 
must  be  used.  Movement  of  the  clavicle  upwards  on 
the  sternum  is  checked  by  the  rhomboid  ligament,  the 
interclavicular  ligament,  the  interarticular  cartilage, 


198  SuRcrcAL  APPIJED  ANATOMY.      [Chap.  xi. 

and  in  a  less  direct  manner  by  the  two  remaining 
ligaments  of  the  joint.  Thus  it  happens  that  dis- 
location upwards  is  the  least  common  of  the  luxations 
at  this  articulation. 

Disease  of  the  stcrno-claviculnr  joint. — 
This  articulation  is  really  divided  into  two  joints  by 
the  interarticular  cartilage,  each  being  provided  with 
a  distinct  synovial  membrane. 

These  joints  are  liable  to  the  ordinary  maladies 
of  joints,  and  it  would  appear  that  the  disease  may 
commence  in,  and  be  for  some  time  limited  to,  one  only 
of  the  synovial  sacs.  In  time  the  whole  articulation 
usually  becomes  involved,  but  even  in  advanced  cases 
the  mischief  is  sometimes  restricted  to  the  synovial 
cavity  on  one  side  of  the  cartilage.  According  to 
some  authors,  this  joint  is  more  frequently  involved 
in  pyaemia  than  is  any  other.  When  effusion  has  taken 
place  into  the  sterno-clavicular  joint,  and  especially 
after  suppuration  has  ensued,  the  swelling  usually 
makes  itself  evident  in  front,  owing  to  the  fact  that 
the  anterior  sterno-clavicular  ligament  is  the  thinnest 
and  least  resisting  of  the  ligamentous  structures  about 
the  articulation.  For  the  same  reason  the  pus  usually 
escapes  from  the  anterior  sm%face,  when  it  discharges 
itself  spontaneously.  It  may,  however,  make  an 
opening  for  escape  through  the  posterior  ligament, 
and  under  these  circumstances  has  found  its  way  into 
the  mediastinum.  The  relations  of  this  joint  to  the 
great  vessels  at  the  root  of  the  neck  should  be  borne 
in  mind.  In  one  case  reported  by  Hilton  a  large 
abscess  formed  in  the  articulation,  and  the  collection, 
receiving  pulsations  from  the  subjacent  artery  (the 
innominate  or  right  subclavian),  was  supposed  at  one 
time  to  be  an  aneurism.  It  is  remarkable  that  disease 
of  this  joint  never  leads  to  anchylosis.  This  cir- 
cumstance may  be  explained  (1)  by  the  constant 
slight  movement  in  the  part  which  prevents  the 


Chap,  xi.]        STER NO-CLAVICULAR  JOINT.  199 

diseased  structures  from  being  kept  at  rest,  (2)  by  the 
occasional  persistence  of  the  interarticular  cartilage, 
and  (3)  by  the  utter  lack  of  adaptability  of  the  two 
bony  surfaces  involved. 

Dislocations  of  the  sterno-clavicular  joint. 
— The  clavicle  may  be  dislocated  from  the  sternum  in 
one  of  three  directions,  which,  given  in  order  of  fre- 
quency, are  :  (1)  forwards,  (2)  backwards,  (3)  upwards. 
The  relative  frequency  of  these  dislocations  can  be 
understood  from  what  has  been  already  said  as  to  the 
action  of  the  ligaments  in  restricting  movements. 
The  displacement  forwards  involves  entire  rupture 
of  the  capsule,  and  more  or  less  damage  to  the 
rhomboid  ligament.  The  head  of  the  bone  carry- 
ing with  it  the  sterno-mastoid,  rests  on  the  front 
of  the  manubrium.  The  dislocation  backwards 
may  be  due  to  direct  or  indirect  violence,  and 
has  occurred  spontaneously  in  connection  with  the 
chest  deformity  in  Pott's  disease.  The  capsule  is 
entirely  torn,  as  is  also  the  rhomboid  ligament.  The 
head  is  found  in  the  connective  tissue  behind  the 
stemo-hyoid  and  sterno-thyroid  muscles.  In  this 
position  it  may  cause  severe  dyspnoea,  or  dysphagia, 
by  pressure  upon  the  trachea  or  gullet.  It  may  so 
compress  the  subclavian  artery  as  to  arrest  the  pulse 
at  the  wrist,  or  so  occlude  the  bi'achio-cephalic  vein  as 
to  produce  semi-coma  (Fig.  17).  In  one  case  the  head 
of  the  bone  had  to  be  excised  to  relieve  a  troublesome 
dysphagia.  In  the  luxation  upwards,  due  usually  to 
indirect  violence,  the  head  rests  on  the  upper  border 
of  the  sternum  between  the  sterno-mastoid  and  sterno- 
hyoid  muscles.  It  involves  more  or  less  complete 
tearing  of  all  the  ligaments  of  the  joint,  together  with 
avulsion  of  the  interarticular  nbro-cartilage. 

The  non-adaptability  of  the  joint  surfaces  in  this 
part  serves  to  explain  the  ease  with  which  these 
luxations  are  usually  reduced,  and  the  difficulty 


200  SURGICAL  APPLIED  ANATOMY,      rchap.  xt 

of  retaining  the    clavicle   in   position   after  it  is  re- 
placed. 

Acromio-claviciilar  joint. — This  articulation 
is  shallow,  and  the  outlines  of  the  two  bones  that 
enter  into  its  formation  are  such  that  no  obstacle 
is  offered  to  the  displacement  of  the  clavicle  from  the 
acromion.  The  joint,  indeed,  depends  for  its  strength 
almost  entirely  upon  its  ligaments.  The  plane  of  the 
joint  would  be  represented  by  aline  drawn  from  above 
downwards  and  inwards  between  the  two  bones.  This 
inclination  of  the  joint  surfaces  serves  to  explain  the 
fact  that  the  usual  luxation  of  this  part  takes  the  form 
of  a  displacement  of  the  clavicle  upwards  on  to  the 
acromion.  The  capsule  that  surrounds  the  joint  is  lax 
and  feeble,  and  it  is  partly  from  its  comparative 
thinness  that  effusion  into  this  joint,  when  it  is  the 
seat  of  disease,  makes  itself  so  soon  visible.  The 
joint,  however,  depends  mainly  for  its  strength  upon 
the  powerful  conoid  and  trapezoid  ligamenta 

As  the  movements  permitted  in  this  joint  may 
be  impaired  by  accident  or  disease,  it  is  well  to 
note  the  part  the  articulation  takes  in  the  move- 
ments of  the  extremity.  The  scapula  (and  with  it, 
of  course,  the  arm),  as  it  glides  forwai'ds  and  back- 
wards upon  the  thorax,  moves  in  the  arc  of  a  circle 
whose  centre  is  at  the  sterno-clavicular  joint,  and 
whose  radius  is  the  clavicle.  As  the  bone  moves 
forwards  it  is  important,  for  reasons  to  be  imme- 
diately given,  that  the  glenoid  cavity  should  also  be 
directed  obliquely  forwards.  This  latter  desirable 
condition  is  brought  about  by  means  of  the  acromio- 
clavicular  joint.  Without  this  joint  the  whole 
scapula  as  it  passed  forwards  with  the  outer  end 
of  the  clavicle  would  precisely  follow  the  line  oi 
the  circle  above  mentioned,  and  the  glenoid  cavity 
would  look  in  an  increasingly  inward  direction.  It 
is  essential  that  the  surface  of  the  glenoid  cavity 


Chap.  XI..1          ACROMIO-CLAVICULAR  JOINT.  2O1 

should  be  maintained  as  far  as  possible  at  right 
angles  to  the  long  axis  of  the  humerus.  When 
these  relations  are  satisfied,  the  humerus  has  the 
support  behind  of  a  stout  surface  of  bone,  and  it  is 
partly  to  obtain  the  value  of  this  support  that  the 
boxer  strikes  out  from  the  side,  i.e.,  with  his  humerus 
well  backed  up  by  the  scapula.  If  there  were  no 
acromio-clavicular  joint  the  glenoid  fossa  would  offer 
little  support  to  the  humerus  when  the  limb 
was  stretched  forwards,  and  a  blow  given  with  the 
limb  in  that  position,  or  a  fall  upon  the  hand  under 
like  conditions,  would  tend  to  throw  the  humerua 
against  the  capsule  of  the  shoulder  joint,  and  so 
produce  dislocation.  Normally,  therefore,  as  the 
scapula  and  arm  advance,  the  angle  between  the 
posterior  border  of  the  acromion  and  the  adjacent 
portion  of  the  clavicle  becomes  more  and  more  acute, 
and  the  glenoid  fossa  is  maintained  with  a  sufficiently 
forward  direction  to  give  substantial  support  to  the 
humerus.*  It  will  thus  be  seen  that  rigidity  of  this 
little  joint  may  be  a  cause  of  insecurity  in  the  articu- 
lation of  the  shoulder,  and  of  weakness  in  certain 
movements  in  the  limb. 

Dislocations  of  the  acroniio  -  clavicular 
joint.  —  The  clavicle  may  be  'displaced  upwards 
on  to  the  acromion  or  downwards  beneath  it.  Pol- 
laillon  has  collected  thirty-eight  cases  of  the  former 
luxation,  and  six  only  of  the  latter.  This  dis- 
proportion is,  in  the  main,  explained  by  the  direc- 
tion of  the  articulating  surfaces  of  the  joint. 
Both  luxations  are  usually  due  to  direct  violence. 
The  dislocation  upwards  is  very  commonly  only  par- 
tial, and  is  associated  only  with  stretching  and  some 
trifling  rupture  of  ligaments.  In  the  complete  form, 
where  the  end  of  the  clavicle  rests  entirely  upon  the 

*  For  an  excellent  account  of  the  mechanism  of  these  joint* 
nee  Morris's  "Anatomy  of  the  Joints,''  p.  202,  et  sea.    1879. 


202  SURGICAL  A r PLIED  ANATOMY.      [Chap,  xi 

acromion,  there  is  rupture,  not  only  of  the  capsule,  but 
also  to  a  greater  or  less  extent  of  the  coraco-clavicular 
ligaments.  In  the  complete  dislocation  doivnwards, 
also,  there  is  a  rupture  of  the  capsule,  with  extensive 
tearing  of  the  conoid  and  trapezoid  ligaments.  These 
luxations  are  usually  easily  reduced,  but  it  will  be 
understood,  from  the  direction  of  the  articular  surfaces, 
that  in  the  displacement  upwai'ds  it  is  very  difficult 
to  retain  the  clavicle  in  situ  when  once  reduced. 

Scapula* — At  the  posterior  aspect  of  the  bone 
the  muscles  immediately  above  and  below  the  spine 
are  somewhat  precisely  bound  down  by  the  deep 
fascia.  Thus,  the  supraspinatus  muscle  is  enclosed  in 
a  fascia,  that,  being  attached  to  the  bone  all  round 
the  origin  of  the  muscle,  forms  a  cavity  open  only 
towards  the  insertion  of  the  muscle. 

The  infraspinatus  and  teres  minor  muscles  are  also 
enclosed  in  a  distinct,  but  much  denser,  fascia  that  is 
attached  to  the  bone  beyond  these  muscles,  and  blends 
in  front  with  the  deltoid  sheath  so  as  to  form  a  second 
enclosed  space.  The  arrangement  of  these  fasciae 
serves  to  explain  the  trifling  amount  of  ecchymosis  that 
usually  follows  upon  fractures  of  the  scapular  blade. 
The  extravasation  of  blood  about  the  fracture  is 
bound  down  by  the  fasciae  over  these  muscles,  and  is 
unable,  therefore,  to  reach  the  siirface. 

Thus  also  pus,  in  the  supra-  and  infraspinous  fossae, 
tends  to  be  pent  up,  and  to  come  forward  in  the  one 
case  at  the  insertion  of  the  subscapular  muscle,  and  in 
the  other  instance  about  the  insei-tion  of  the  teres 
minor.  Owing  to  the  rigidity  of  the  fascia  over  the 
infraspinatus  and  teres  minor  muscles,  it  happens  that 
dense  tumours  growing  from  this  fascia  may  readily 
be  mistaken  for  growths  from  the  bone  itself. 

The  inferior  angle  of  the  scapula  is  crossed  by  a 
part  of  the  latissimus  dorsi,  and  by  means  of  this  muscle 
is  retained  in  contact  with  the  thorax.  In  certain 


Chap,  xi.]  THE  SCATULA.  203 

injuries  the  angle  may  slip  from  beneath  the  muscle 
and  appear  as  a  marked  projection.  This  lesion  is  pro- 
ductive of  some  loss  of  power  in  the  limb.  In  many 
cases  where  this  accident  is  supposed  to  have  occurred, 
it  is  probable  that  the  symptoms  present  are  due 
rather  to  paralysis  of  the  nerve  of  Bell. 

Fractures  of  the  scapula,  and  especially  of 
the  body  of  the  bone,  are  not  common,  owing  to  the 
mobility  of  the  part  and  the  thick  muscles  that  cover 
in  and  protect  its  thinner  portions.  It  rests  also 
upon  a  soft  muscular  pad,  and  derives,  no  doubt, 
additional  security  from  the  elasticity  of  the  ribs. 

The  most  common  lesion  is  a  fracture  of  the 
acromion  process.  This  is  often  but  a  separation  of  the 
epiphysis.  There  are  two,  sometimes  three,  epiphy- 
seal  centres  for  the  acromion.  Ossification  appears  in 
them  about  puberty,  and  the  entire  epiphysis  joins 
with  the  rest  of  the  bone  from  the  twenty-second  to  the 
twenty-fifth  year.  Several  cases  of  supposed  fracture 
of  the  acromion  united  by  fibrous  tissue  are  probably  but 
instances  of  an  imperfectly-united  epiphysis,  and  may 
have  been  independent  of  injury.  In  fractures  of  the 
process  much  displacement  is  quite  uncommon,  owing 
to  the  dense  fibrous  covering  the  bone  derives  from  the 
two  muscles  attached  to  it.  This  dense  periosteum  also 
explains  the  circumstance  that  many  fractures  are 
incomplete  and  crepitus  often  absent.  When  the 
fracture  is  in  front  of  the  clavicular  joint,  displace- 
ment of  the  arm  is  impossible.  When  it  involves  the 
joint,  a  dislocation  of  the  collar-bone  is  common. 
When  behind  the  joint,  the  arm,  having  lost  its 
inipport  from  the  thorax,  is  displaced  in  somewhat  the 
same  way  as  obtains  in  the  common  fracture  of  the 
clavicle.  The  coracoid  process  may  present  a  genuine 
fracture,  or  may  be  separated  as  an  epiphysis.  As  an 
epiphysis,  it  joins  the  main  bone  about  the  age  ot 
seventeen.  In  spite  of  the  po"vrerful  muscles  attached 


2O4  SURGICAL  APPLIED  ANATOMY,      rchap.  xi. 

to  it,  the  displacement  is  usually  slight,  inasmuch  as 
the  coraco  -  clavicular  ligaments  are  seldom  torn. 
These  ligaments,  it  may  be  noted,  are  attached  to  the 
base  of  the  process.  In  some  few  cases  the  process 
has  been  torn  off  by  muscular  violence. 

Among  the  more  iisual  fractures  of  the  body  of  the 
scapula  is  a  transverse  or  oblique  fracture  of  its  blade 
below  the  spine.  Owing  to  the  infraspinatus,  sub- 
scapularis,  and  other  muscles  being  attached  to  both 
fragments,  none  but  a  trifling  displacement  is  usual. 
A  fracture  may  occur  through  the  surgical  neck.  The 
surgical  neck  is  rcpi-esented  by  a  narrowed  part 
of  the  bone  behind  the  glenoid  fossa,  and  in  the 
line  of  the  suprascapular  notch.  The  smaller  frag- 
ment will,  therefore,  include  the  coracoid  process, 
the  larger,  the  acromion.  The  amount  of  deformity 
in  these  cases  depends  upon  whether  the  coraco- 
clavicular  and  acromio-clavicular  ligaments  are  entire 
or  torn.  If  they  be  torn,  the  s'mall  fragments  and 
the  entire  limb  are  displaced  downwards,  and  the 
injury  somewhat  resembles  a  subglenoid  dislocation. 
From  this,  however,  it  is  distinguished  by  the 
crepitus,  by  the  ease  with  which  the  deformity  is 
removed  and  the  equal  ease  with  which  it  returns, 
by  the  position  of  the  head  of  the  humerus  in  regard 
to  the  glenoid  fossa,  and  by  the  conspicuous  fact  that 
the  coracoid  process  is  displaced  downwards  with  the 
limb. 

Tumours  of  various  kinds  grow  from  the  scapula 
and  mainly  from  the  spongy  parts  of  the  bone,  viz., 
the  spine,  the  neck,  the  inferior  angle.  The  bone 
may  be  removed  entire,  with  or  without  amputa- 
tion of  the  tipper  limb.  The  main  vessels  to  be  noted 
in  connection  with  this  operation  are  the  supra- 
scapular  at  the  superior  border  of  the  bone,  the 
posterior  scapular  about  the  vertebral  border,  the 
subscapular  running  along  the  lower  border  of  the 


Chap.  XL] 


THE  AXILLA. 


205 


subscapularis  muscle,  the  dorsalis  scapulae  crossing  the 
axillary  edge  of  the  bone,  and  the  acromial  branches 
of  the  acromio-thoracic  artery. 

The  axilla. — The  axilla  may  be  regarded  sur- 
gically as  a  passage  between  the  neck  and  the  xipper 
limb.  Axillary  tumours  and  abscesses  may  spread  up 
into  the  neck,  and  in  like  manner  cervical  growths  and 
purulent  collections 
may  extend  to  the  «  • 
arm-pit.  The  skin 
forming  the  base  of 
the  axilla  is  pro- 
vided with  many 
short  hairs  and  with 
numerous  sebaceous  f 
and  sudoriferous 
glands.  In  this  in- 
tegument small  su- 
perficial abscesses 
are  often  met  with, 
that  arise  usually 
from  suppuration 
of  these  glandular 
structures,  and  that 
are  brought  about 
by  the  friction  of 

the    Skin  against  the  Fig.  18.- Vertical  Section  through  the  Axilla 
i      i  •  s\     •  all(l  Shoulder-joint    (Rudmger). 

clothing.  Owing  to  1§  Sraimla .  ,§  bmm,rus.  ^  clavick, .  4>  acromion  . 
the  tendency  of  the  imS^n'd^ie^tofl^'^u^ex'artSOT™!^ 
axillary  integument  ^^^^i^^SSSSS^^ei^^mSm 

to       become       Chafed         niagnua;  i,  axillary  artery  ;;',  axillary  vein. 

and  inflamed  under 

friction,  the  axilla  is  not  a  good  locality  to  select  for 
the  use  of  the  mercurial  inunction  as  applied  in 
syphilis.  Beneath  the  skin  and  superficial  fascia?  is 
the  axillary  fascia,  and  beyond  this  dense  membrane 
is  the  axillary  space.  The  connective  tissue  with 


206  SURGICAL  APPLIED  AN  ATOMY.      [Chap,  xi 

which  the  axillary  space  is  mainly  occupied  is  very 
loose,  and,  while  this  laxity  favours  greatly  the  free 
movement  of  the  arm,  it  at  the  same  time  permits  of 
the  formation  of  large  purulent  collections  and  im- 
mense extravasations  of  blood. 

It  is  important  to  remember  the  disposition  of 
the  fasciae  about  this  region.  There  are  three  layers 
principally  concerned.  (1)  The  deep  pectoral  fascia 
that  covers  in  and  encloses  the  pectoralis  major. 
(2)  The  clavi-pectoral  fascia  that,  adherent  above  to 
the  clavicle,  fills  in  the  space  between  that  bone  and 
the  pectoralis  minor,  then  splits  to  invest  this  muscle, 
and  joins  the  deep  pectoral!  layer  at  the  anterior  fold 
of  the  axilla  to  form  with  it  the  axillary  fascia.  The 
upper  part  of  this  fascia  is  generally  known  as  the 
costo-coracoid  membrane.  The  whole  membrane  is 
sometimes  known  also  as  "  the  suspensory  ligament  of 
the  axilla,"  since  it  draws  up  the  axillary  fascia  towards 
the  clavicle,  and  is  mainly  instrumental  in  producing 
the  "  hollow  "  of  the  armpit.  (3)  The  axillary  fascia, 
that  is  formed  by  the  union  of  the  two  preceding 
I  tscise,  and  stretches  across  the  base  of  the  axilla  from 
its  anterior  to  its  posterior  fold. 

Abscess  about  the  axillary  region  may  be 
considered  (1)  when  it  is  beneath  the  pectoralis  major, 
or  between  the  two  pectoral  muscles,  and  (2)  when  it  is 
beneath  the  pectoralis  minor  and  clavi-pectoral  fascia, 
and  therefore  in  the  axillary  space.  (1)  An  abscess 
in  this  situation  is  placed  between  the  deep  pectoral 
and  the  clavi-pectoral  fasciae,  the  latter  separating 
it  from  the  axillary  space.  Such  an  abscess  under- 
mines the  great  pectoral,  and  tends  to  present  either 
at  the  anterior  margin  of  the  axilla,  or  in  the  groove 
between  the  great  pectoral  and  deltoid  muscles,  being 
guided  thither  by  the  attachment  of  the  fascia-. 
(2)  A  purulent  collection  in  the  axilla  may  soon  fill 
that  space  and  distend  it  entirely.  Its  progress 


Cfaap.  xi.)  THE  AXILLA.  207 

towards  the  skin  is  arrested  by  the  axillary  fascia,  its 
progress  backwards  by  the  serratus  magnus  muscle, 
which,  by  its  attachment  to  the  scapula,  hermetically 
closes  the  axillary  space  behind.  In  front  the 
advance  of  the  abscess  is  prevented  by  the  pectoral 
muscles  and  clavi-pectoral  fascia,  while  on  the  inner 
side  is  the  unyielding  thorax,  and  on  the  outer  side 
the  upper  limb.  The  abscess,  therefore,  as  it  fills  the 
axilla  pushes  forwards  the  pectoralis  major,  more  or 
less  obliterates  the  hollow  of  the  armpit,  thrusts  back 
the  scapula,  and  widens  the  angle  between  the  serratus 
magnus  and  the  subscapularis  muscles.  There  is  a 
great  tendency,  therefore,  for  unrelieved  abscesses  to 
extend  upwards  into  the  neck,  that  being  the  direction 
in  which  the  least  amount  of  resistance  is  encountered. 
From  the  neck  the  purulent  collection  may  extend 
into  the  mediastinum.  In  one  case  an  axillary 
abscess,  set  up  by  shoulder-joint  disease,  perforated 
the  first  intercostal  space,  and  set  up  fatal  pleurisy. 

In  opening  an  axillary  abscess,  and,  indeed,  in 
most  incisions  into  this  space,  the  knife  should  be 
entered  at  the  centre  of  the  floor  of  the  axilla,  i.e., 
midway  between  the  anterior  and  posterior  margins, 
and  near  to  the  inner  or  thoracic  side  of  the  space. 
The  vessels  most  likely  to  be  damaged  by  an 
indiscreet  incision  are  the  subscapular,  running  along 
the  lower  border  of  the  subscapularis  muscle ;  the 
long  thoracic,  following  the  lower  border  of  the  small 
pectoral ;  and  the  main  vessels  lying  close  to  the 
hnmerus.  The  knife,  if  properly  entered,  should  be 
midway  between  the  two  first-named  vessels,  and 
quite  away  from  the  main  trunks.  There  is  an 
artery  (the  external  mammary)  that  sometimes  comes 
off  as  the  lowest  branch  of  the  axillary  trunk,  and 
crosses  the  middle  of  the  axilla,  to  be  distributed  to 
the  thorax  below  the  long  thoracic.  This  vessel  would 
probably  be  wounded  in  the  incision  above 


2oS  SURGICAL  APPLIED  ANATOMY.     [Chap,  xi 

The  artery  is,  however,  very  inconstant,  is  small,  and 
is  not  far  below  the  surface.  It  is  usually  met  with 
in  female  subjects. 

Lymphatic  glands. — The  axillary  glands  are 
numerous,  and  of  much  surgical  importance.  They 
may  be  arranged  in  three  sets.  (1)  The  greater 
number  are  placed  along  the  axillary  vessels,  and 
reach  up  into  the  neck  along  those  vessels  so  as 
to  form  a  chain  continuous  with  the  cervical 
glands.  They  receive  mainly  the  lymphatics  of  the 
upper  limb,  and  are  enlarged  in  inflammatory  and 
other  affections  of  that  part.  (2)  Other  glands  lie 
upon  the  st>rratus  rnagnus  muscle  on  the  thoracic  side 
of  the  axilla,  and  just  behind  the  lower  border  of  the 
pectoral  muscles.  They  receive  the  lymphatics  from 
the  front  of  the  chest,  the  principal  lymph  vessels 
of  the  breast,  and  the  superficial  lymphatics  of  the 
abdomen  as  low  down  as  the  umbilicus.  Their 
efferent  vessels  for  the  most  part  pass  on  to  join  the 
chief  axillai'y  glands.  These  glands  will  be  the 
first  to  be  enlarged  in  certain  breast  affections,  and 
after  blistering  and  other  superficial  inflammations, 
etc.,  of  the  chest  and  upper  abdomen.  Paulet  has 
seen  them  affected  in  inflammation  of  the  hand. 
(3)  The  remaining  glands  are  situated  at  the  back  of 
the  axilla,  along  the  subscapular  vessels.  They  are 
joined  by  the  lymphatics  from  the  back. 

It  may  here  be  convenient  to  note  that  one  or 
two  glands  are  commonly  found  in  the  groove  between 
the  deltoid  and  pectoralis  major  muscles.  They 
receive  some  vessels  from  the  outer  side  of  the 
arm  and  a  part  of  the  shoulder.  The  superficial 
lymphatics  over  the  upper  part  of  the  deltoid  go 
to  the  cervical  glands  (Tillaux),  over  the  lower  half 
to  the  axilla.  The  lymphatics  from  the  supraspinous 
fossa  follow  the  suprascapular  artery,  and  join  the 
lowest  cervical  glands.  The  superficial  lymphatics  of 


Chap  xi.)  THE  AXILLA.  209 

the  back  that  converge  to  the  axilla  are  derived  from 
the  neck  over  the  trapezius  muscle,  and  from  the 
whole  dorsal  and  lumbar  regions  as  far  down  as  the 
iliac  crest. 

The  removal  of  axillary  glands  is  an  operation 
frequently  undertaken.  It  will  be  understood  from 
their  position  that  these  bodies,  when  diseased,  are 
very  apt  to  become  adherent  to  the  axillary  vessels, 
and  especially  to  the  vein.  The  latter  vessel  has 
frequently  been  wounded  during  the  removal  of 
gland  tumours,  and  in  one  case  at  least  the  artery 
was  accidentally  cut  (Holmes). 

The  axillary  vessels. — The  axillary  vein  is 
formed  by  the  union  of  the  basilic  with  the  two  venae 
comites  of  the  brachial  artery.  This  union  commonly 
takes  place  at  the  lower  border  of  the  subscapular 
muscle,  and  the  vein  is  therefore  shorter  than  the 
artery.  Sometimes  the  vein  does  not  exist  as  a  single 
trunk  until  just  below  the  clavicle.  This  condition, 
when  it  exists,  is  very  unfavourable  to  operations 
upon  the  artery,  as  many  transverse  branches  cross 
that  vessel  to  unite  the  veins  that  lie  on  either  side  of 
it.  The  axillary  vein,  being  comparatively  near  the 
heart,  is  readily  influenced  as  regards  its  contained 
blood  by  the  inspiratory  movement.  Thus  it  happens 
that  in  many  instances  of  wound  of  the  vessel,  or  of 
its  larger  tributaries,  air  has  been  drawn  into  the 
venous  canal  and  death  has  ensued.  The  entrance 
of  air  into  the  main  vein  is  perhaps  aided  by 
the  circumstance  that  the  costo-coracoid  membrane 
(upper  part  of  clavi-pectoral  fascia)  is  adherent 
to  the  vessel,  and  thus  tends  to  maintain  it  in  a 
patent  condition  when  wounded.  This  connection 
with  the  fascia  is  supposed  by  some  to  in  part  ac- 
count for  the  furious  bleeding  that  occurs  from  this 
vein  when  it  is  divided. 

The  vein  is  more  often  wounded  than  is  the  artery,  it 
0—4 


?jo  SuKcrcAL  APPLIED  ANATOMY.      iChap.  xi 

being  larger,  more  superficial,  and  so  placed  as  to  more 
or  less  overlap  the  arterial  trunk.  On  the  other  hand, 
in  injury  to  the  vessels  by  traction,  as,  for  example,  in 
reducing  dislocations,  the  artery  suffers  more  frequently 
than  the  vein.  In  all  positions  of  the  upper  limb  the 
artery  keeps  to  the  outer  angle  of  the  axillary 
space.  The  relation  of  the  vein,  however,  to  the  first 
part  of  the  axillary  artery,  the  part  above  the 
pectoralis  minor,  is  modified  by  the  position  of  the 
limb.  Thus,  when  the  arm  hangs  by  the  side  the 
vein  is  to  the  inner  side  of  the  artery,  and  a  little  in 
front  of  it,  but  when  the  limb  is  at  a  right  angle  with 
the  trunk  the  vein  is  drawn  so  far  in  front  of  the 
artery  as  to  almost  entirely  conceal  that  vessel. 

Aneurism  is  very  frequent  in  the  axillary  artery,  a 
fact  to  be  explained  by  the  nearness  of  the  vessel  to  the 
heart,  by  the  abrupt  curve  it  presents,  by  its  suscepti- 
bility to  frequent  and  extensive  movements,  and  by  its 
liability  to  share  in  the  many  lesions  of  the  upper 
limb.  In  violent  and  extreme  movements  of  the  limb 
the  artery  may  be  more  or  less  torn,  especially  if  its 
walls  are  already  diseased. 

In  ligaturing  the  first  part  of  the  axillary  artery 
it  is  well  to  note  that  the  pectoralis  major  has  some- 
times a  cellular  interval  between  two  planes  of 
muscle  fibre,  and  this  may  be  mistaken  for  the  space 
beneath  it  (Heath).  If  the  pectoralis  minor  has 
an  origin  from  the  second  rib,  it  may  more  or 
less  entirely  cover  the  artery  and  require  division. 
The  cord  of  the  brachial  plexus  nearest  to  the  artery 
may  be  mistaken  for  that  vessel,  or  easily  included  in 
a  ligature  intended  for  it.  A  ready  guide  to  the 
axillary  vessels  in  this  operation  is  to  follow  the 
cephalic  vein. 

In  applying  a  ligature  to  the  third  part  of  the 
artery,  it  should  be  borne  in  mind  that  a  muscular 
slip  sometimes  crosses  the  vessels  obliquely,  passing 


dnp.  xi.]  THE  DELTOID.  ?n 

from  the  latissimus  dorsi  to  join  the  pectoralis  major, 
coraco-brachialis,  or  biceps  muscles.  This  slip  may 
give  rise  to  confusion  during  the  operation,  and  may 
be  mistaken  for  the  coraco-brachialis. 

The  axillary  nerves.  —  Any  of  the  axillary 
nerves  may  be  injured  by  a  wound,  the  median 
being  the  most  frequently  damaged,  and  the  musculo- 
spiral  the  least  frequently.  The  comparative  im- 
munity of  the  latter  is  explained  by  its  deep 
position,  its  situation  at  the  inner  and  posterior 
aspect  of  the  limb,  and  its  large  size.  The  nerves  are 
very  seldom  torn  by  a  traction  on  the  limb  short  of 
more  or  less  complete  avulsion.  Indeed,  if  forcibly 
stretched,  they  are  disposed  rather  to  become  torn 
away  from  their  attachments  to  the  spinal  cord  than  to 
give  way  in  the  axilla.  Thus,  Flaubert  records  a  case 
where  the  last  four  cervical  nerves  were  torn  away 
from  the  cord  during  a  violent  attempt  to  reduce  a 
dislocated  shoulder. 

The  deltoid  region. — This  region,  comprising 
as  it  does  the  "  point "  of  the  shoulder,  is  limited 
in  all  parts  by  the  deltoid  muscle.  The  deltoid 
covers  the  upper  end  of  the  humerus  and  the 
shoulder  joint.  Between  the  joint  and  the  surface, 
therefore,  are  only  the  skin  and  superficial  fascia,  the 
deltoid  in  its  sheath,  and  some  loose  connective  tissue 
(the  subdeltoid  tissue)  in  which  is  found  the  great 
subacromial  bursa.  This  subdeltoid  tissue  sometimes 
assumes  the  form  of  a  distinct  thick  membrane,  and 
may  have  an  important  influence  upon  the  locali- 
sation of  purulent  collections  proceeding  from  the 
joint.  The  fatty  tissue  over  the  deltoid  is  a  favourite 
seat  for  liponiata,  and  it  is  in  this  situation  that  the 
tendency  of  these  growths  to  change  their  position 
is  sometimes  seen.  Thus,  Erichsen  records  a  casi 
where  the  tumour  slid  downwaixls  from  the  shoulder 
bo  the  breast. 


zia  SURGICAL  APPLIED  ANATOMY.      (Chap.  xi. 

Emerging  from  the  interval  between  the  two  teres 
muscles,  and  winding  horizontally  round  the  shaft  of 
the  humerus,  quite  close  to  the  bone,  and  about  the 
line  of  the  surgical  neck,  are  the  circumflex  nerve  and 
posterior  circumflex  artery.  This  nerve  affords  an 
example  of  an  arrangement  pointed  out  by  Mr.  Hilton, 
viz.,  that  a  principal  nerve  to  a  joint  not  only  supplies 
the  articular  surfaces,  but  also  some  of  the  main 
muscles  that  move  that  joint  and  the  skin  over  those 
rrmscles.  This  nerve  supplies  the  shoulder  joint, 
the  deltoid  and  teres  minor  muscles,  and  the  skin  over 
the  lower  two-thirds  of  the  shoulder  and  upper  part 
of  the  triceps.  "  The  object  of  such  a  distribution  of 
nerves  to  the  muscular  and  articular  structures  of  a 
joint,  in  accurate  association,  is  to  ensure  mechanical 
and  physiological  consent  between  the  external 
muscular  or  moving  force  and  the  vital  endurance  of 
the  parts  moved,  viz.,  of  the  joints,  thus  securing  in 
health  the  true  balance  of  force  and  friction  until 
deterioration  occurs"  (Hilton).  This  nerve  is  frequently 
damaged  in  injuries  to  the  shoulder.  It  may  be 
severely  bruised  by  a  simple  contusion  of  the  part, 
and  this  bruising  may  be  followed  by  paralysis  of  the 
deltoid.  It  would  appear,  however,  that  damage  to 
the  circumflex  is  much  less  frequent  after  contusions 
of  the  shoulder  than  was  formerly  maintained.  It 
will  also  be  readily  vinderstood  that  the  nerve  is  often 
torn  in  fractures  of  the  surgical  neck  of  the  humerus, 
in  dislocations  of  that  bone  (especially  the  luxation 
backwards),  and  in  violent  attempts  at  reducing  such 
dislocations.  The  nerve,  from  its  position,  is  very  apt 
to  be  seriously  pressed  upon  by  growths  springing 
from  the  upper  end  of  the  humerus.  From  its  con- 
nection with  the  joint,  it  follows  that  in  chronic 
inflammation  of  that  part  the  inflammation  may  extend 
along  the  nerve,  producing  a  neuritis  that  may  lead  to 
paralysis  of  the  deltoid  (Erb). 


chap,  xi.)  THE  SHOULDER-JOINT.  213 

The  shoulder-joint. — From  one  surgical  point 
of  view,  joints  may  be  divided  into  (1)  those  that 
depend  for  their  strength  mainly  upon  ligaments ; 
(2)  those  that  are  mechanically  strong,  and  that 
derive  their  stability  to  a  great  extent  from  the 
arrangement  of  their  component  bones ;  and  (3)  those 
that  rely  for  their  support  principally  upon  muscles. 
As  an  example  of  the  first  kind  may  be  cited  the 
sterno-clavicular  joint,  of  the  second  form  the  elbow- 
joint,  and  of  the  thii'd  the  shoulder-joint.  The  articu- 
lation the  least  prone  to  dislocation  is  the  one  that 
derives  its  strength  from  tough  unyielding  ligaments, 
while  the  one  most  often  luxated  belongs  to  the  third 
variety,  its  strength  being  greatly  dependent  upon 
muscles  that  may  be  taken  by  surprise,  and  that  may 
themselves,  from  disordered  action,  prove  sources  of 
weakness.  These  are,  of  course,  not  the  only  features 
in  the  etiology  of  dislocation.  A  great  deal  depends 
upon  the  amount  of  movement  permitted  in  a  given 
joint,  and  the  degree  of  leverage  that  can  be  brought 
to  bear  upon  its  parts. 

The  arch  formed  by  the  coracoid  and  acromion 
processes  and  the  ligament  between  them  forms  an 
essential  support  to  the  head  of  the  huinerus,  and  is 
an  important  constituent  of  the  articulation.  With 
this  arch  the  humeral  head  is  in  immediate  relation, 
although  not  in  actual  contact  (Fig.  18).  In  paralysis 
of  the  deltoid  the  head  may  be  separated  by  some 
distance  from  the  coracoid  process,  and  Nannoni 
records  the  case  of  a  child  with  old  standing  paralysis 
of  the  deltoid,  between  whose  humeral  head  and  acro- 
mial  vault  four  fingers  could  be  lodged.  It  is  well  to 
note  that  at  least  two-thirds  of  the  head  of  the  bone 
are  not  in  contact  with  the  glenoid  cavity  when  the 
arm  hangs  by  the  side,  and  Anger  points  out  that  in 
this  position  three-fourths  of  the  circumference  of  the 
humeral  head  are  in  front  of  a  vertical  line  drawn 


21-',  SURGICAL  APPLIED  ANATOMY.      [Chap.  xi. 

from  the  anterior  border  of  the  acromion  process.  In 
this  posture,  also,  the  head  is  wholly  to  the  outer  side 
of  the  coracoid  process.  The  margin  of  the  glenoid 
cavity  is  more  prominent  on  the  inner  than  on  the 
outer  side,  while  the  strongest  part  of  the  margin  and 
the  broadest  part  of  the  fossa  are  below.  This  is  sig- 
nificant, since  it  points  to  an  attempt  to  strengthen  a 
part  of  the  joint  that  practice  shows  to  be  the  weakest 
in  the  articulation,  viz.,  the  lower  and  inner  portion 
of  the  capsule.  It  is  at  this  place  that  the  head  of  the 
bone  leaves  the  joint  in  dislocation  of  the  shoulder. 

The  capsule  of  the  shoulder-joint  is  very  lax,  and 
would  lodge  a  bone-head  twice  as  large  as  that  of  the 
humerus.  According  to  Henry  Morris,  no  one  part 
of  the  capsule  is  constantly  thicker  than  the  rest,  as  is 
the  case  in  the  hip-joint.  The  inner  surface  of  the 
capsule  looks  into  the  axilla,  and  is  there  free  between 
the  two  tuberosities,  between  the  lesser  one  in  front 
and  the  posterior  part  of  the  greater  process  behind. 
It  is  between  these  two  projections  that  the  humeral 
head  can  be  felt  through  the  axilla. 

Of  the  oursae  about  the  joint,  the  subacromialbursa 
is  the  one  most  frequently  the  seat  of  disease,  and  this 
sac,  when  distended  with  fluid,  may  be  mistaken  for  the 
results  of  chronic  inflammation  of  the  joint  (Fig.  18). 

Experiment  shows  that  the  walls  of  this  bui'sa  may 
be  actually  torn  in  twists  of  the  arm,  especially  when 
either  flexed  or  extended  .(Naiicrede).  When  the  sac 
is  distended  most  pain  is  elicited  in  the  position  of 
abduction,  for  in  this  posture  the  bursal  walls  are 
normally  folded  up,  so  as  to  form  a  sort  of  collar  in 
advance  of  the  greater  tuberosity.  When  the  walls 
are  thickened  and  distended  by  inflammation,  abduc- 
tion must  press  the  bursa  very  forcibly  under  the 
acromion,  and  so  cause  pain.  In  elderly  people  the 
sac  sometimes  communicates  with  the  joint. 

The  biceps  tendon  strengthens  the  upper  part 


Chap,  xi.]  THE  SHOULDER  JOINT.  215 

of  the  joint,  keeps  the  humerus  against  the  glenoid 
cavity  in  the  various  positions  of  the  limb,  and  pre- 
vents the  head  of  the  bone  from  being  pulled  too 
closely  upwards  under  the  acromion.  The  tendon 
may  be  ruptured,  and  in  such  a  case,  in  addition  to 
the  general  weakening  of  the  limb  and  the  peculiar 
projection  formed  by  the  contraction  of  the  muscle, 
the  head  of  the  humerus  is  usually  drawn  upwards 
and  forwards  until  arrested  by  the  coraco-acromial 
arch.  Thus,  a  kind  of  slight  false  dislocation  may  be 
produced.  In  certain  violent  wrenches  of  the  limb  the 
tendon  may  slip  from  its  groove  and  be  displaced  to 
one  or  other  side,  usually  to  the  inner  side.  In  these 
cases  also  the  head  is  drawn  up  under  the  acromion, 
and  is  prominent  in  front,  while  abduction  is  rendered 
less  free  than  is  normal  owing  to  the  great  tuberosity 
being  sooner  brought  in  contact  with  tho  acromion. 

Joint  disease. — This  articulation  is  liable  to  all 
forms  of  joint  disease.  The  capsule,  as  just  stated,  is 
very  lax,  but  the  humerus  is  kept  in  contact  with  the 
glenoid  cavity  by  atmospheric  pressure.  In  joint 
disease,  however,  the  effusion  may  effect  a  considerable 
separation  of  the  two  bones.  Braune,  having  pierced 
the  glenoid  cavity  through  the  supraspinous  fossa, 
injected  tallow  at  considerable  pressure  into  the  joint. 
When  fully  distended  the  humerus  was  found  to  be 
separated  from  the  scapula  by  more  than  half  an  inch, 
and  this  may  serve  to  explain  the  lengthening  of  the 
limb  often  noted  in  joint  disease  of  this  part  with 
much  effusion.  When  the  greatest  degree  of  disten- 
sion of  the  capsule  was  reached  the  humerus  became 
slightly  extended  and  rotated  in.  It  is  significant  that 
in  shoulder- joint  disease  it  is  com-inon  for  the  arm  to 
be  found  close  to  the  side,  the  elbow  carried  a  little 
back  (extension),  and  the  limb  rotated  inwards.  This 
position  may  also  be  due  to  the  rigid  contraction  of 
the  muscles  about  the  joint  that  is  usually  observed. 


216  SURGICAL  APPLIED  ANATOMY.     r,cnap.  XL 

When  such  contractions  exist  it  may  be  inferred  that 
the  powerful  latissimus  dorsi  has  a  little  advantage 
over  its  opponents,  and  may  be  answerable  for  the  rota- 
tion in  and  slight  projection  backwards  of  the  arm. 
The  inner  part  of  the  epiphyseal  cartilage  is  just  with- 
in the  capsule,  the  outer,  anterior,  and  posterior  parts 
are  entirely  subperiosteal.  It  happens,  therefore,  that 
the  pus  in  suppurative  epiphysitis  will  find  its  way 
into  the  joint. 

There  may  be  three  diverticula  from  the  synovial 
membrane  :  (1)  One  that  runs  some  way  down  the 
bicipital  groove  with  the  tendon ;  (2)  a  cul-de-sac 
beneath  the  subscapularis,  formed  by  a  communication 
between  the  synovial  cavity  and  the  bursa  under  that 
muscle  ;  and  (3)  a  cul-de-sac  of  like  nature  beneath 
the  infraspinatus  muscle.  The  first-named  is  constant; 
the  second  is  frequently  present ;  the  third  is  rare. 
When  the  joint  is  filled  with  effusion,  the  capsule  is 
evenly  distended  and  the  shoulder  evenly  rounded. 
Special  projections  usually  occur  at  the  seats  of  the 
diverticula.  Thus  a  swelling  often  appears  early  in 
the  course  of  a  synovitis  in  the  groove  between  the 
pectoralis  major  and  the  deltoid  muscles,  and  this 
swelling  may  appear  bilobed,  being  cut  in  two  by  the 
unyielding  biceps  tendon  (Paulet).  Fluctuation  can 
best  be  felt  by  examining  the  uncovered  part  of  the 
capsule  in  the  axilla  beyond  the  subscapular  muscle. 
When  the  joint  suppurates  pus  usually  escapes  at  one 
of  the  cul-de-sacs  just  mentioned,  most  often  through 
the  one  that  follows  the  biceps  tendon.  Pus  may  thus 
extend  for  some  way  along  the  bicipital  groove.  Pus 
escaping  through  the  subscapular  cul-de-sac  is  apt  to 
spread  between  the  muscle  and  the  venter  of  the 
scapula,  and  to  present  at  the  lower  and  back  part  of 
the  axilla.  Purulent  collections  beneath  the  deltoid 
are  nearly  always  conducted  towards  the  anterior 
aspect  of  the  limb,  being  unable  to  proceed  backwards 


Chap  xi.]  THE  SHO  ULDER  JOINT.  217 

owing  to  the  denseness  of  the  fascia  covering  in  the 
deltoid  and  infraspinous  muscles.  In  one  recorded 
case,  pus  that  had  escaped  from  the  shoulder-joint 
followed  the  course  of  the  musculo-spiral  nerve,  and 
opened  on  the  outer  side  of  the  elbow. 

The  various  forms  of  anchylosis  are  common  at  the 
shoulder-joint,  and  to  afford  a  freer  range  of  move- 
ment to  the  limb  in  the  more  intractable  of  these 
cases,  Tillaux  proposes  to  divide  the  clavicle. 

Dislocations. — Dislocations  at  this  joint  are 
more  common  than  at  any  other  joint  in  the  body. 
This  is  explained  by  the  shallowness  of  the  glenoid 
fossa,  the  large  size  and  globular  shape  of  the  head  of 
the  humerus,  the  extensive  movements  of  the  arm, 
the  long  leverage  it  affords,  and  the  dependence  of  the 
articulation  for  its  strength  mainly  upon  muscles. 
The  upper  limb  and  shoulder  are  also  peculiarly  ex- 
posed to  injury. 

The  principal  forms  of  luxation  of  the  humerus  at 
the  shoulder  are :  1.  Subcoracoid,  forwards  and  a 
little  downwards ;  the  usual  form.  2.  Subglenoid, 
downwards  and  a  little  forwards  ;  rare.  3.  Subsj)inous, 
backwards;  rare. 

In  all  complete  dislocations  the  head  of  the  bone 
leaves  the  joint  cavity  through  a  rent  in  the  capsule. 
In  so-called  "  false  luxations  "  the  capsule  is  not  torn. 
For  example,  in  the  cadaver,  if  the  deltoid  be  divided 
the  humeral  head  can  be  displaced  under  the  coracoid 
process  without  rupture  of  the  capsule,  and  the  same 
thing  may  occur  during  life,  in  cases  where  the  muscle 
has  long  been  paralysed. 

In  all  cases  of  dislocation  at  this  joint  the  primary 
displacement  is  always  downwards  into  the  axilla.  It 
is  well  known  that  dislocations  at  the  shoulder  are 
usually  due  to  violence  applied  to  the  limb  while 
the  arm  is  abducted,  or  to  severe  direct  violence 
forcing  the  bone  downwards.  Now  when  the  limb  is 


218  SURGICAL  APPLIED  ANATOMY.     [Chap,  xi. 

abducted  the  head  of  the  humerus  projects  below  the 
glenoid  fossa,  and  rests  upon  the  inferior  and  least 
protected  part  of  the  capsule.  The  fibres  of  this 
portion  of  the  capsule  being  tightly  stretched  in  this 
position,  it  requires  no  extraordinary  force  to  tear  the 
ligament  and  drive  the  bone  into  the  a«xilla. 

Thus  it  happens  that  in  luxations  at  this  joint  the 
rent  in  the  capsule  is  at  its  inferior  and  inner  aspect. 
The  head  of  the  bone  being  thus  driven  downwards 
into  the  axilla,  may,  for  certain  reasons,  remain  there 
(subglenoid  form),  or  more  usually  it  will  be  drawn 
forwards  and  inwards  by  the  powerful  pectoralis 
major,  aided  by  other  muscles  whose  action  is  now 
less  resisted  (subcoracoid  form)  ;  and  lastly,  the  direc- 
tion of  the  violence  being  applied  markedly  from  in 
front,  the  head  of  the  bone  may  be  thrust  backwards 
under  the  acromioii  or  spinous  processes  (subspinous 
form).  The  overwhelming  frequency  of  the  subcora- 
coid variety  is  explained  by  the  greater  advantage  at 
which  those  muscles  act  that  draw  the  bone  forwards, 
in  comparison  with  those  that  would  draw  it  back- 
wards, and  by  the  very  trifling  opposition  offered  to  the 
passage  of  the  head  forwards  when  compared  with  the 
substantial  obstacles  in  the  way  of  its  passage  back- 
wards under  the  scapular  spine. 

Features  common  to  all  dislocations  at 
the  shoulder. — As  the  roundness  of  the  deltoid 
depends  to  a  great  extent  upon  the  presence  beneath 
it  of  the  humeral  head,  and  as  in  all  these  luxations 
(save  perhaps  in  the  slighter  grades  of  the  subspinous 
form)  the  head  is  removed  practically  from  its 
connection  with  the  deltoid,  that  muscle  is  always 
more  or  less  flattened.  This  flattening  is  augmented 
by  the  stretching  of  the  muscle,  whicli  in  some  degree 
is  constantly  present.  Stretching  of  the  deltoid  in- 
volves abduction  of  the  arm,  and  this  symptom  is 
fairly  constant  in  all  the  luxations.  The  biceps  being 


Chap,  xi.]  THE  SHOULDER  JOINT.  2 1 9 

also  more  or  less  unduly  tense,  the  elbow  is  found 
flexed  and  the  fore-arm  supinated.  In  every  form 
there  is  some  increase  in  the  vertical  circumference  of 
the  axilla,  since  the  head,  having  left  theglenoid  fossa, 
must  occupy  some  part  comprised  within  that  cir- 
cumference. Again,  Dr.  Dugas  has  pointed  out  that 
"  if  the  fingers  of  the  injured  limb  can  be  placed  by 
the  patient,  or  by  the  surgeon,  upon  the  sound 
shoulder  while  the  elbow  touches  the  thorax  (a  con- 
dition that  obtains  in  the  normal  condition  of  the 
joint),  there  can  be  no  dislocation ;  and  if  this  can- 
not be  done  there  must  be  one,  for  no  other  injury  than 
a  dislocation  can  induce  this  physical  impossibility." 
This  depends  upon  the  fact  that  in  consequence  of  the 
rotundity  of  the  thorax  it  is  impossible  for  both  ends 
of  the  humerus  to  touch  it  at  the  same  time,  and  in 
luxation  at  the  shoulder  the  upper  end  of  the  bone  is 
practically  touching  the  trunk.  Lastly,  from  the 
position  of  the  great  vessels  and  nerves  it  will  be  seen 
that  in  the  subcoracoid  and  subglenoid  luxations  the 
head  of  the  bone  may  press  injuriously  upon  those 
structures.  Thus  may  result  oedema  of  the  limb  and 
severe  pain  or  loss  of  muscular  power.  The  artery 
is  usually  saved  by  its  greater  elasticity ;  but  Berard 
reports  a  case  of  displacement  forwards  where  the 
axillary  artery  was  so  compressed  by  the  humeral 
head  as  to  induce  gangrene  of  the  limb. 

The  close  connection  of  the  circumflex  nerve  with  the 
humerus  renders  it  very  liable  to  injury,  especially  in 
the  subglenoid  and  subspinous  forms  of  dislocation. 

Special  anatomy  of  cadi  form. — 1.  Sub- 
coracoid.— The  articular  head  of  the  humerus  lies  on 
the  anterior  surface  of  the  neck  of  the  scapula,  and  the 
anatomical  neck  rests  on  the  anterior  lip  of  the  glenoid 
fossa.  The  head  is  thus  placed  immediately  below  the 
coracoid  process,  and  is  in  front  of,  internal  to,  and 
a  little  below,  its  normal  site  The  great  tubcrosity 


22O 


SURGICAL  APPLIED  ANATOMY.     [Chap.  xi. 


faces  the  empty  glenoid  cavity  (Fig.  19).  The  sub- 
scapularis  muscle  is  stretched  over  the  head  of  the 
humerus,  and  is  usually  in  some  part  torn.  The  supra- 
spinatus,  infraspinatus,  and  teres  minor  are  stretched 

or  torn,  or  the 
great  tuberosity 
may  even  be 
wrenched  off.  The 
c  o  r  a  c  o  -  brachialis 
and  short  head  of 
the  biceps  are 
tense,  and  are 
immediately  in 
front  of  the  head 
of  the  humerus 
instead  of  to  its 
inner  side.  The 
long  tendon  of  the 
biceps  is  deflected 
downwards  and 
outwards.  It  is 
sometimes,  al- 
though rarely, 
torn  from  its 
groove.  The  del- 
toid is  put  upon  the  stretch.  The  prominence 
formed  by  the  humeral  head  in  the  front  of  the 
axilla  depends  to  some  degree  upon  the  amount  of 
rotation.  If  the  bone  be  rotated  out  the  projec- 
tion is  most  distinct ;  but  if  rotated  in,  its  head 
sinks  into  the  axilla  and  is  brought  more  in  contact 
with  the  scapula  than  with  the  skin.  The  head  of 
the  bone  being  always  carried  a  little  downwards  some 
lengthening  must  in  all  cases  really  exist;  but  with 
the  ordinary  method  of  measuring  the  limb  this 
lengthening  may  be  replaced  by  a  normal  measure 
ment,  or  even  by  apparent  shortening,  if  the  head  of 


Fig.  19. — Subcoracoid  Dislocation  of  the 
Humerus. 


Chap.  XL]  THE    SHOULDER-fOINT.  221 

the  bone  be  carried  a  good  deal  forwards  and  inwards, 
and  the  limb  be  abducted.  When  the  head  has  left 
the  glenoid  cavity  abduction  tends  to  bring  the 
external  condyle  nearer  to  the  acromion,  and  these 
are  the  two  points  between  which  the  measurement  is 
usually  taken.  Thus  the  apparent  length  of  the  arm 
depends  mainly  upon  the  degree  of  abduction  of  the 
humerus,  or  the  obliquity  of  the  axis  of  the  bone. 

2.  Silbglcnoid.  —  The  head  is  below,  and  a 
little  in  front  of  and  internal  to,  its  normal  position. 
It  cannot  go  directly  downwards,  owing  to  the  situa- 
tion of  the  long  head  of  the  triceps,  but  escapes  in 
the  interval  between  that  muscle  and  the  subscapularis. 
The  articular  head  rests  on  the  anterior  aspect  of  the 
triangular  surface  just  below  the  glenoid  fossa  that 
gives  origin  to  the  triceps.  The  upper  border  of  the 
great  tuberosity  is  in  close  relation  with  the  lower 
margin  of  the  joint.  It  is  generally  stated,  on  the 
authority  of  Malle,  that  the  circumstance  which  pre- 
vents the  head  of  the  bone  from  being  drawn  upwards 
is  the  entirety  of  the  anterior  part  of  the  capsule,  the 
rent  being  in  the  lower  part  only  of  that  ligament. 
The  subscapularis  muscle  is  much  stretched  or  torn, 
and  the  head  usually  lies  beneath  its  tendon,  ami 
upon  some  fibres  of  the  disturbed  muscle.  The  supra- 
spinatus  will  be  torn.  The  infraspinatus  will  be 
stretched  or  torn,  and  the  two  teres  muscles  will  not 
be  much  affected  unless  there  be  considerable  abduc- 
tion of  the  arm.  The  coraco-brachialis  and  biceps  will 
be  stretched,  but  owing  to  the  amount  of  abduction 
usually  present  the  biceps  tendon  is  but  little  deflected 
from  a  straight  line.  The  deltoid  is  greatty  stretched, 
and  its  tension  serves  to  produce  the  extreme  flatten- 
ing of  the  shoulder,  and  the  great  abduction  common 
in  this  injury.  Some  lengthening  is  seldom  absent, 
although  it  is  always  modified  by  the  abduction  that 
exists. 


222 


APPLIED  ANATOMY.     [Chap.  XL 


3.  Subspiiious.  —  The  head  usually  rests  on 
the  posterior  surface  of  the  neck  of  the  scapula,  the 
groove  of  the  anatomical  neck  of  the  humerus  corre- 
sponding to  the  posterior  lip  of  the  glenoid  fossa. 
The  head  is  thus  placed  beneath  th.e  acromion ;  but  it 

may  be  displaced  still 
farther  back,  and  may 
rest  on  the  dorsum 
scapula1,  and  beneath 
the  scapula  i1  spine 
(Fig.  20).  The  sub- 
scapularis  tendon  is 
drawn  right  across  the 
glenoid  fossa,  and  is 

/ff^m     fi/i/:  •   /      often     torn      from     its 

jjji      mi»       n(/     /      attachment.      The  head 
f  Im  mli  tii        I/  /       pushes  back  the  hinder 

/  I       ill!.,  Ytf    part  of  the  deltoid' the 

infraspinatus,  and  teres 
minor  muscles.  These 
latter  cover  the  bone, 
and  are  stretched  over 
it.  The  supraspinatus 


Fig.  20.— Sub; 


>ST> 
11. 


inous  Dislocation  of 
.irnerus. 


is  tense,  as  is  also  the 
biceps,  while   the  teres 

major  and  latissimus  dorsi  are  relaxed.  The  great 
pectoral  is  rendered  unduly  tense,  and  this  sei-ves 
in  part  to  explain  the  rotation  inwards  of  tire 
huraerus,  and  the  adduction  forwards,  that  ai'e  usually 
observed,  those  movements  being  more  or  less  un- 
opposed. The  circumflex  nerve  is  often  torn. 

In  reducing  dislocations,  especially  such  as  are  of 
long  standing,  serious  damage  may  be  inflicted  on  the 
axillary  structures.  The  axillaiy  artery  suffers  most 
frequently,  the  vein  rarely,  and  the  nerves  still  less 
often.  The  artery,  being  placed  externally,  is  apt  to 
contract  adhesions  to  the  soft  parts  covering  the  head 


Chr-j.  xi. i        UPPER  E.vn  OF  HUMF.KVS.  273 

of  the  displaced  bone,  and  to  be,  therefore,  torn  when 
those  parts  are  disturbed. 

Fractures  of  the  upper  end  of  the  Im- 
nicrus. — 1.  Anatomical  neck.  The  upper  part 
of  the  capsule  is  exactly  attached  to  the  anatomical 
•neck,  and  in  this  situation  the  fracture  may  run 
beyond  the  ligament  and  be  partly  extracapsular. 
The  lower  part  of  the  capsule  is  inserted  some  little 
way  below  the  anatomical  neck,  and  in  this  position, 
therefore,  the  lesion  must  be  intracapsular.  From 
the  line  of  attachment  of  the  lower  part  of  the  capsule 
to  the  humerus,  fibres  are  reflected  upwards  to  the 
margin  of  the  articular  cartilage  on  the  head  of  the 
bone.  These  fibi'es,  if  unruptured,  may  serve  to  con- 
nect the  fragments.  If  entirely  separated,  the  head  of 
the  bone  must  necrose,  having  no  such  source  of  blood 
supply  as  the  head  of  the  femur  derives  from  the 
round  ligament.  It  is  easy  for  the  small  and  com- 
paratively dense  upper  fragment  to  be  driven  into  the 
wide  surface  of  cancellous  bone  exposed  on  the  upper 
surface  of  the  lower  fragment.  When  impaction 
occurs,  there  may  be  some  flattening  of  the  deltoid, 
since  the  head  is  rendered  of  less  dimensions  by  that 
impaction,  and  consequently  causes  a  less  projection  of 
the  deltoid.  I  may  be  possible  to  detect  the  impac- 
tion by  examination  through  the  axilla  when  the  arm 
is  fully  abducted.  The  difficulty  of  obtaining  crepitus 
in  non-impacted  fractures  will  be  obvious  when  the 
small  size  of  the  upper  fragment  is  considered,  together 
with  its  great  mobility,  and  the  obstacles  in  the  way 
of  so  fixing  it  that  one  broken  end  may  be  rubbed 
against  the  other. 

The  arnoimt  of  displacement  is  to  be  measured  by 
the  laxity  of  the  capsule.  The  usual  deviation  is  a 
projection  of  the  upper  end  of  the  lower  fragment 
towards  the  anterior  and  inner  side  of  the  articulation, 
brought  about  mainly  by  the  muscles  attached  to  the 


224  SlfRGfCAL    APPLIED    ANATOMY.        [Chap.  Xl. 

bicipital  groove.  In  no  case  could  the  two  bone-ends 
overlap. 

2.  Separation  of  the  upper  epipliysis. — The 

lower  border  of  this  epiphysis  is  represented  by  a 
horizontal  line  crossing  the  bone  at  the  base  of  the 
great  tuberosity,  and  placed  between  the  anatomical 
and  surgical  necks.  It  would  be  fairly  indicated  by  a 
transverse  saw-cut  through  the  widest  part  of  the  bone. 
The  three  component  nuclei  of  this  epiphysis  (head, 
greater  and  lesser  tuberosities)  fuse  together  about  the 
fifth  year,  and  the  entire  mass  joins  the  shaft  about 
the  twentieth  year.  The  upper  fragment  may  be 
carried  and  rotated  a  little  outwards  by  the  muscles 
attached  to  the  great  tuberosity,  while  the  lower  frag- 
ment is  drawn  inwards  and  forwards  by  the  muscles 
inserted  into  the  bicipital  groove.  Thus,  a  part  of  the 
smooth  upper  end  of  the  lower  fragment  commonly 
forms  a  distinct  projection  below  the  coracoid  process. 
In  such  case  the  axis  of  the  limb  would  be  altered,  and 
the  elbow  carried  a  little  from  the  side.  Often,  how- 
ever, the  displacement  is  solely  in  the  antero-posterior 
direction,  the  lower  fragment  projecting  forwards. 
So  wide  are  the  two  bone  surfaces  at  the  seat  of 
injury  that  it  is  scarcely  possible  for  them  to  overlap 
one  another. 

3.  Surgical  neck. — The  surgical  neck  is  situated 
between  the  bases  of  the  tuberosities  and  the  insertions 
of  the  latissimus  dorsi  and  teres  major  muscles.     A 
common  displacement  of  parts  is  the  following.     The 
upper  fragment  is  carried  out  and  rotated  out  by  the 
supra-  and  infraspinatus  and  teres  minor.     The  upper 
end  of  the  lower  fragment  is  drawn  upwards  by  the 
ileltoid,  biceps,  coraco-brachialis,  and  triceps,  inwards 
by  the  muscles  attached  to  the  bicipital  groove,  and 
forwards  by   the   great   pectoral.     Thus,   it  forms  a 
projection  in  the  axilla,  and  the  axis  of  the  limb  is 
altered  so  that  the  elbow  projects  from  the  side.     Tina 


Chap.  XI.] 


UPPER  END  OF  HUM^RUS. 


displacement,  however,  is  by  no  means  constant. 
Pean,  Anger,  and  others  maintain  that  the  usual 
deformity  is  a  projection  of  the  tipper  end  of  the  lower 
fragment  forwards,  and  that  this  deviation  is  due  to 
the  nature  and  direction  of  the  violence,  and  not  to 
muscular  action.  In  some  cases  there  is  no  displace- 
ment, the  broken  ends  being  retained  in  situ,  pro- 
bably, by  the  biceps  tendon  and  the  long  head  of  the 
triceps.  In  at  least  one  instance  (Jarjavay)  the  lower 
fragment  was  so  drawn  upwards  and  outwards, 
apparently  by  the  deltoid,  as  to  nearly  pierce  the  skin 
of  the  shoulder.  Hamilton  comes  to  the  general  con- 
clusion "  that  com- 
plete or  sensible 
displacement  is 
less  common  at 
this  fracture  than 
in  most  other  frac- 
tures," and  in  this 
conclusion  many 
surgeons  agree. 

Amputation 
at  the  shoulder 
joint.  —  "Flap 
method  ;  "  "  del- 
toid flap."  In  the 
outer  flap  are  only 
the  deltoid  and  a 
few  small  vessels 
derived  from  the 
aeromio  -  thoracic 
and  the  two  cir- 
cumflex arteries. 
The  cephalic  vein 
and  descending 
branch  of  the  aeromio  -  thoracic  artery  are  in  the 
inner  flap.  The  anterior  and  posterior  borders  of  the 
p— 4 


Fig.  21.— Amputation  at  Shoulder- joint  (flap 

method)   (Agit/). 
a,  < : li-iiuiil  cavity ;    6,  deltoid  ;    c,    long    bead   of 

biceps;  J,  pectoral!:)  major;  <•,  biiviis  and  coraco- 

brachialis ;  /,  latissimus  dorsi  and  tores  major; 

g,  triceps;    1,  axillary  vessels ;    2,  drcumqex 

vessels  ;  .t,  brafhial  plexus. 


226  SURGICAL  APPLIED  AN  ATOM?.    [Chap,  xiu 

inner  flap  show  portions  of  the  deltoid  muscle. 
Along  its  lower  border  from  before  backwards  are 
sections  of  the  pectoralis  major,  the  short  head 
of  the  biceps  and  coraco-brachialis,  the  axillary 
vessels  and  nerves,  the  latissimus  dorsi  and  teres 
major,  the  triceps,  and  the  posterior  portion  of  the 
deltoid.  The  trunks  of  the  posterior  circumflex 
artery  and  nerve  are  found  divided  on  the  posterior 
part  of  the  surface  of  the  flap,  between  the  sections  of 
the  triceps  and  deltoid,  and  not  far  from  the  angle 
between  the  two  flaps. 

Oval  method  (Spence).  The  parts  cut  and  the 
order  of  their  division  are  pi'actically  the  same  as 
obtain  in  the  anterior  and  inferior  borders  of  the  two 
flaps  made  in  the  previous  method.  The  anterior 
incision  being  a  little  more  vertical  than  is  the  gap 
between  the  two  flaps,  divides  more  of  the  pectoralis 
major  and  cuts  the  cephalic  vein  higher  up.  The 
posterior  circumflex  vessels  and  nerve  are  separated 
from  the  bone  by  the  finger  and  are  retained,  one 
advantage  of  the  procedure  being  that  only  a  few  of 
the  terminal  branches  of  that  artery  are  divided. 


CHAPTER  XIL 

THE    ARM. 

THE  arm,  upper  arm,  or  brachial  region  is  con- 
sidered to  extend  from  the  axilla  above  to  the  region 
of  the  elbow  below. 

Surface  anatomy.  —  La  women,  and  in  those 
who  are  fat,  the  outline  of  the  arm  is  rounded  aud  fairly 
regular.  It  is  less  regular  in  the  muscular,  in  whom 
it  may  be  represented  by  a  cylinder,  somewhat 


Chap,  xn.)  TIIK  ARM.  227 

flattened  on  either  side  and  unduly  prominent  in  front 
(biceps  muscle).  The  outline  of  the  biceps  muscle  is 
distinct,  and  on  either  side  of  it  is  a  groove.  The 
inner  of  the  two  grooves  is  by  far  the  more  con- 
spicuous. It  runs  from  the  bend  of  the  elbow  to  the 
axilla,  and  indicates  generally  the  position  of  the 
basilic  vein  and  brachial  artery.  The  outer  groove 
is  shallow,  and  ends  above  at  the  insertion  of  the 
deltoid  muscle.  So  far  as  it  goes  it  marks  the  position 
of  the  cephalic  vein. 

The  insertion  of  the  deltoid  can  be  well  made  out, 
and  is  an  important  landmark.  It  indicates  very 
precisely  the  middle  of  the  shaft  of  the  humerus,  is 
on  the  same  level  with  the  insertion  of  the  coraco- 
hrachialis  muscle,  and  marks  the  upper  limit  of  the 
brachial  is  anticus.  It  corresponds  also  to  the  spot 
where  the  cylindrical  part  of  the  humeral  shaft  joins 
the  prismatic  portion,  to  the  point  of  entrance  of  the 
nutrient  artery,  and  to  the  level  at  which  the  musculo- 
spiral  nerve  and  superior  profunda  artery  cross  the 
back  of  the  bone. 

When  the  arm  is  extended  and  supinated,  the 
brachial  artery  corresponds  to  a  line  drawn  along  the 
inner  border  of  the  biceps,  from  the  outlet  of  the 
axilla  (at  the  junction  of  its  middle  and  anterior 
thirds)  to  the  middle  of  the  bend  of  the  elbow.  The 
artery  is  superficial,  and  can  be  felt  in  its  entire 
extent.  In  its  upper  two-thirds  it  lies  on  the 
inner  aspect  of  the  shaft  of  the  humerus,  and  can 
be  compressed  against  the  bone  by  pressure  in  a 
direction  outwards  and  slightly  backwards.  In  its 
lower  third  the  liurnerus  lies  behind  it,  and  com- 
pression, to  be  effectual,  should  be  directed  back- 
wards. 

The  inferior  profunda  would  be  represented  by  a 
line  drawn  from  the  inner  side  of  the  humeral  shaft 
at  its  middle  to  the  back  part  of  the  internal  coudyle. 


228  SURGICAL  APPLIED  ANATOMY,    [Chap.  xn. 

The  nutrient  artery  enters  the  bone  at  its  inner  aspect, 
opposite  the  deltoid  insertion,  and  the  anastomotic 
vessel  comes  off  about  two  inches  above  the  bend  of 
the  elbow. 

The  ulnar  nerve  follows  first  the  brachial  artery, 
and  then  a  line  drawn  from  the  inner  side  of  that 
vessel,  about  the  level  of  the  insertion  of  the  coraco 
brachialis  to  the  gap  between  the  inner  condyle  and 
the  olecranon.  The  main  part  of  the  internal  cuta- 
neous nerve  is  beneath  the  inner  bicipital  groove, 
while  the  superficial  portion  of  the  musculo-cutaneous 
corresponds  to  the  lower  termination  of  the  outer 
groove. 

The  arm. —  The  skin  of  the  arm  is  thin  and 
smooth,  especially  in  front  and  at  the  sides.  It  is 
very  mobile,  being  but  loosely  attached  to  the  deeper 
parts  by  a  lax  subcutaneous  fascia.  In  circular  am- 
putations of  the  arm  this  looseness  of  the  integument 
allows  it  to  be  sufficiently  drawn  up  by  traction  with 
the  hand  only.  It  is  from  the  integument  covering 
the  anterior  surface  of  the  biceps  that  the  flap  is 
fashioned  in  Tagliacozzi's  operation  for  the  restoration 
of  the  nose.  The  fineness  of  the  skin  of  this  part,  and 
its  freedom  from  hairs,  render  it  very  suitable  for  this 
procedure.  The  scanty  attachments  of  the  skin  of  the 
arm  allow  it  to  be  readily  torn  or  stripped  away  in 
lacerated  and  contused  wounds.  Sometimes  in  these 
lesions  large  flaps  of  integument  are  violently  dis- 
sected up.  The  looseness  of  the  subcutaneous  tissues 
favours  greatly  the  spread  of  inflammatory  processes, 
while  its  comparative  thinness  allows  of  the  early 
manifestation  of  ecchynioses. 

The  limb  is  completely  invested  by  a  deep  fascia, 
the  brachial  aponeurosis,  as  by  a  sleeve.  The  fascia 
is  held  down  at  the  sides  by  the  two  intermuscular 
septa  which  are  attached  along  the  outer  and  inner 
margins  of  the  humerus,  running  from  the  deltoid 


Chan.  XI1.1  TlfE  AtiM.  229 

insertion  to  the  outer  condyle  on  the  one  side,  and 
from  the  coraco-brachialis  insertion  to  the  inner  condyle 
on  the  other.  By  means  of  this  aponeurosis  and  its 
septa  the  arm  is  divided  into  two  compartments,  that 
can  be  well  seen  in  transverse  sections  of  the  limb. 
These  compartments  serve  to  confine  inflammatory 
and  hsemorrhagic  effusions.  The  anterior  of  the  two 
spaces  has  the  less  substantial  boundaries,  owing  to 
the  thinness  of  the  brachial  fascia  as  it  covers  the 
biceps.  Effusions  can  readily  pass  from  one  compart- 
ment to  the  other  by  following  the  course  of  those 
structures  that,  by  piercing  the  intermuscular  septa, 
are  common  to  both  spaces.  These  are  the  musculo- 
spiral  and  ulnar  nerves,  the  superior  and  inferior 
profunda,  and  anastomotic  arteries.  The  principal 
structures  that  pierce  the  brachial  aponeurosis  itself 
are  the  basilic  vein,  a  little  below  the  middle  of  the 
arm,  the  internal  cutaneous  nerve,  about  the  middle, 
and  the  external  cutaneous  nerve,  just  above  the 
elbow.  The  two  first  named  are  in  the  inner  bicipital 
groove,  and  the  last  named  in  the  outer. 

The  skin  over  the  point  of  insertion  of  the  deltoid 
was  commonly  selected  as  a  suitable  place  for  an  issue 
at  a  time  when  that  remedy  was  popular.  The  reasons 
for  such  selection  were  the  absence  of  blood-vessels  of 
any  size  in  the  parts  beneath,  and  the  freedom  of  the 
spot  from  muscular  movement.  The  brachialis  anticus 
is  closely  adherent  to  the  bone,  while  the  biceps  is 
free.  It  follows,  therefore,  that  in  section  of  these 
muscles,  as  in  amputation,  the  latter  muscle  retracts 
more  considerably  than  does  the  former.  It  is  well, 
therefore,  in  performing  a  circular  amputation,  to 
divide  the  biceps  muscle  first,  and  then  after  it  has 
retracted  k>  cut  the  brachialis  anticus. 

The  bracliial  artery. — The  line  of  this  vessel 
has  already  been  given.  It  is  well  to  note  that  in  the 
very  muscular  the  artery  may  be  overlapped  to  a 


230  •          SURGICAL  APPLIEL  ANATOMY,    [chap.  xn. 

considerable  extent  by  the  biceps  muscle.  Compression 
of  the  brachial,  unless  performed  carefully  with  the 
fingers,  can  hardly  avoid  at  the  same  time  compression 
of  the  median  nerve.  Thus  no  doubt  arises  the  severe 
pain  that  is  often  complained  of  when  tourniquets,  or 
circular  indiarubber  bands,  are  applied  to  the  limb. 
It  must  also  be  remembered  that  the  internal 
cutaneous  nerve  lies  in  front  of  the  vessel,  or  close  to 
its  inner  side,  until  it  pierces  the  fascia ;  that  the  ulnar 
nerve  lies  along  the  inner  side  of  the  artery  as  far  as 
the  coraco-brachialis  insertion,  and  that  behind  the 
commencement  of  the  vessel  is  the  musculo-spiral 
nerve.  The  venae  comites  are  placed  one  on  either 
side  of  the  artery,  and  communicate  frequently  with 
one  another  by  short  transverse  branches  which 
directly  cross  the  vessel,  and  which  may  give  trouble 
in  operations  upon  the  artery.  If  in  ligaturing  the 
artery  at  its  middle  third  the  arm  rests  upon  any 
support  the  triceps  may  be  pushed  up  and  mistaken 
for  the  biceps.  If  the  incisions  be  too  much  to  the 
inner  side  the  basilic  vein  may  be  cut,  or  the  ulnar 
nerve  exposed  and  mistaken  for  the  median.  Tillaux 
states  that  in  the  operation  a  large  inferior  profunda 
artery  has  been  taken  for  the  brachial.  Inasmuch 
as  the  median  nerve  often  derives  distinct  pulsation 
from  the  subjacent  vessel,  it  happens  that  in  the 
living  subject  it  has  been  confused  with  the  main 
artery  itself. 

The  nrasculo-spiral  nerve,  from  its  close 
contact  with  the  bone,  which  it  crosses  at  the  level 
of  the  deltoid  insertion,  is  frequently  injured  and 
toin.  Thus  it  has  been  damaged  in  severe  contusions, 
in  kicks,  in  stabs,  in  bites  from  horses,  and  very 
frequently  in  fractures  of  the  humeral  shaft ;  or  the 
nerve  may  be  sound  at  the  time  of  fracture,  and 
become  subsequently  so  involved  in  the  callus  formed 
as  to  load  to  paralysis  of  the  parts  it  supplies.  In  a 


chnp.  xii.]  THE  ARM.  231 

case  reported  by  Tillaux,  where  paralysis  followed 
some  time  after  a  fracture,  the  nerve  was  found 
embedded  in  callus,  and  on  cutting  some  of  the 
redundant  mass  away  a  good  recovery  followed.  In 
several  instances  the  nerve  has  been  paralysed  by  the 
pressure  of  the  head  when  a  man  has  slept  with  his 
head  resting-  on  the  arm  in  the  position  of  full 
supination  &ua  abduction.  It  is  said  to  be  often 
paralysed  in  Russian  coachmen  who  fall  asleep  with 
the  reins  wound  round  the  upper  arm.  It  has  also 
been  frequently  damaged  by  the  pressure  of  badly 
constructed  crutches,  .especially  those  that  afford  nc 
proper  support  for  the  hand.  Indeed,  it  is  the  nerve 
most  often  affected  in  "  crutch  paralysis,"  the  ulnar 
being  the  trunk  that  suffers  next  in  frequency. 

Fracture  of  the  shaft  of  the  iiiinicms  is 
usually  due  to  direct  violence.  The  shaft  may,  how- 
ever be  broken  by  indirect  violence,  and  of  all  bones 
the  humerus  is  said  to  be  the  one  most  frequently 
fractured  by  muscular  action.  As  examples  of  the 
latter  may  be  noted  the  throwing  of  a  ball,  the 
clutching  at  a  support  to  prevent  a  fall,  and  the  so- 
called  trial  of  strength  known  as  "wrist  turning." 
When  the  bone  is  broken  above  the  deltoid  insertion 
the  lower  fragment  may  be  drawn  upwards  by  the 
biceps,  triceps,  and  deltoid,  and  outwards  by  the  last- 
named  muscle  j  while  the  upper  fragment  is  drawn 
inwards  by  the  muscles  attached  to  the  bicipital 
groove.  When  the  fracture  is  below  the  deltoid 
insertion,  the  lower  end  of  the  upper  fragment  may 
be  carried  outwards  by  that  muscle,  while  the  lower 
fragment  is  drawn  upwards  to  its  inner  side  by  the 
biceps  and  triceps.  The  deformity,  however,  as  a 
rule  depends  much  more  upon  the  nature  and  direction 
of  the  force  that  breaks  the  bone  than  upon  any 
muscular  action.  The  displacements  just  noted  may 
be  met  with,  but  usually  they  are  quite  independent 


232  SURGICAL  APPLIED  ANATOMY.    [Chap.  x»i. 

of  the  relation  of  the  deltoid  insertion  to  the  seat  of 
fracture,  and  cannot  be  tabulated.  The  weight  of  the 
arm  seldom  allows  of  more  than  three-quarters  of  an 
inch  of  shortening. 

The  humerus  is  more  frequently  the  seat  of 
non-union  after  fracture  than  is  any  other  bone. 
This  result  is  quite  independent  of  the  position 
of  the  fracture  in  relation  to  the  nutrient  artery. 
Hamilton's  explanation  is  briefly  this  :  the  fracture  is 
usually  so  adjusted  that  the  elbow  is  flexed ;  this 
joint  soon  becomes  fixed  by  muscular  rigidity,  and 
when  any  movement  is  made  as  if  to  flex  or  extend 
the  fore  arm  on  the  arm,  that  movement  no  longer 
occurs  at  the  elbow  joint,  but  at  the  seat  of  fracture. 
Thus,  if  the  arm  be  in  a  sling,  and  the  patient  allows 
the  hand  to  drop  by  relaxing  that  sling,  it  is  main- 
tained that  the  bulk  of  that  movement  will  take  place 
about  the  fracture  line.  Tbsre  are  many  objections 
to  this  theory.  If  true,  the  tendency  to  movement 
about  the  fragments  would  be  the  greater  the  farther 
the  fracture  is  from  the  elbow  joint,  but  non-union  is 
more  common  at  the  middle  than  at  the  upper  third 
of  the  shaft.  Probably  many  causes  conspire  to 
bring  about  non-union  of  fractures  of  this  bone, 
among  which  may  be  mentioned  the  imperfect  fixing 
of  the  joint  above  the  fracture,  and  the  inadequate 
support  afforded  to  the  elbow,  whereby  the  weight 
of  the  arm  and  of  the  splints  tends  to  drag  the 
lower  fragment  out  of  the  proper  line  it  should  form 
with  the  upper  fragment.  The  most  effective  cause 
would  appear  to  be  due  to  the  entanglement  of 
muscular  tissue  between  the  broken  ends,  for  it 
must  be  remembered  that  the  shaft  of  the  bone  is 
closely  surrounded  by  muscular  fibres  that  are  directly 
adherent  to  its  surfaces.  Thus,  in  an  oblique  fracture 
the  end  of  one  fragment  may  be  driven  into  the 
brachialis  anticus,  while  the  other  end  projects  iuto 


Chap.  XII.] 


THE  ARM. 


233 


the  substance  of  the  triceps,  and  immediate  contact 
of  the  bones  be  consequently  prevented. 

Amputation  through  the  middle  of  the 
arm. — Circular  method  :  The  parts  divided  in  this 
amputation  are  fully  shown  in  Fig.  22.  Flap 
method  :  Two  flaps  of  about  equal  size  and  shape 
may  be  cut  antero-posteriorly,  the  arm  being  well 
rotated  outwards. 
In  the  anterior  flap 
would  be  the  biceps 
and  the  greater  part 
of  the  brachialis 
antic  us,  with  the 
musculo  -  cutaneous 
nerve  between  them, 
and  a  small  piece  , 
of  the  triceps  from 
the  inner  side  of 
the  limb.  The 

brachial  vessels,  the  ^ 

median    and     ulnar  <* 

nerves,  and  possibly 

the  inferior  profunda  Fig>  22.— A  Transverse  Section  through  the 
artery  are  also  middle  of  the  Arm  (Braune). 

found  in  this  flap, 
about  the  inner 
angle  of  the  stump. 

The  basilic  vein  and  internal  cutaneous  nerve 
lie  about  the  inner  border  of  the  anterior  flap, 
and  the  cephalic  vein  about  its  outer  border.  In 
the  posterior  flap  would  be  the  triceps,  any  small 
part  of  the  outer  portion  of  the  brachialis  not 
divided  in  the  anterior  flap,  the  superior  profunda 
artery,  and  the  musculo-spiral  nerve.  If  the  amputa- 
tion be  lower  down  in  the  arm,  the  ulnar  nerve 
and  inferior  profunda  artery  may  be  found  in 
the  posterior  instead  of  the  anterior  flap.  Since  the 


dia«  nerve ;S,uinar  nerve;  4, musculo-spiral 


2.34  SURGICAL  APPLIED  ANATOMY.  [Chap.  xni. 

nutrient  artery  enters  the  bone  about  the  insertion 
of  the  coraco-brachialis  and  runs  towards  the  elbow, 
it  would  be  divided  in  these  amputations,  and  might 
give  trouble. 


CHAPTER  XIII. 

THE    REGION    OF    THE    ELBOW. 

Surface  anatomy. — On  the  anterior  aspectof  the 
elbow  are  seen  three  muscular  elevations.  One,  above 
and  in  the  centre,  corresponds  to  the  biceps  and  its 
tendon ;  while,  of  the  two  below  and  at  the  sides,  the 
outer  corresponds  to  the  supinator  longus  and  the 
common  extensor  mass,  and  the  inner  to  the  pronator 
radii  teres  and  the  common  set  of  flexor  muscles. 
The  arrangement  of  these  elevations  is  such  that  two 
grooves  are  formed,  one  on  either  side  of  the  biceps 
and  its  tendon.  The  grooves  diverge  above,  and  join 
the  outer  and  inner  bicipital  grooves,  while  below 
they  meet  over  the  most  prominent  part  of  the 
tendon,  and  thus  form  together  a  V-shaped  depression. 
The  distinctness  of  these  details  depends  upon  the 
thinness  and  muscular  development  of  the  individual. 
In  the  inner  of  the  two  grooves  are  to  be  found  the 
median  nerve  and  the  bi-achial  artery  and  its  veins ; 
while  deeply  placed  ?  alow  the  outer  groove  are  the 
terminations  of  the  musculo-spiral  nerve  and  superior 
profunda  artery,  with  the  small  radial  recurrent 
vessel.  The  biceps  tendon  can  generally  be  very 
distinctly  felt.  Its  outer  border  is  more  evident  than 
is  its  inner  edge,  owing  to  the  connection  of  the 
bicipital  fascia  with  the  latter  side  of  the  tendon. 
Extending  transversely  across  the  front  of  this  region 
is  a  crease  in  the  integument,  the  "  fold  of  the  elbow." 


Chan.  XIFI.J  REGION   CF    El. ROW.  235 

This  fold  is  not  a  straight  line,  but  is  convex  below. 
It  is  placed  some  little  way  above  the  line  of  the 
articulation,  and  its  lateral  terminations  correspond  to 
the  tips  of  the  two  condylar  eminences.  In  backward 
dislocations  of  the  elbow  the  lower  end  of  the  humerus 
appears  about  one  inch  below  this  fold,  whereas  in  a 
fracture  of  the  humerus  just  above  the  condyles  the 
fold  is  either  opposite  to  the  prominence  formed  by 
the  lower  end  of  the  upper  fragment,  or  is  below  it 
This  crease  is  obliterated  on  extension. 

At  the  apex  of  the  V-shaped  depression,  about  the 
spot  where  the  biceps  tendon  ceases  to  be  distinctly 
felt,  and  at  the  outer  side  of  that  tendon,  the  median 
vein  divides  into  the  median  basilic  and  the  median 
cephalic.  At  the  same  spot  also  the  deep  median  vein 
joins  the  superficial  vessels.  The  median  basilic  vein 
can  be  seen  to  cross  the  biceps  tendon,  to  follow  more 
or  less  closely  the  groove  along  the  inner  border  of  the 
muscle,  and  to  join,  a  little  above  the  internal  condyle, 
with  the  posterior  ulnar  vein  to  form  the  basilic  trunk. 
The  median  cephalic  following  the  groove  at  the  outer 
margin  of  the  biceps  joins,  about  the  level  of  the 
external  condyle,  with  the  radial  vein  to  form  the 
cephalic  vein.  The  braclual  artery  bifurcates  about 
a  finger's  breadth  below  the  centre  of  the  bend  of  the 
elbow.  "  The  coronoid  process  of  the  ulna  can  be 
indistinctly  felt,  if  firm  pressure  is  made  in  the 
triangular  space  in  front  of  the  joint  "  (Chiene).  The 
points  of  the  two  condyles  can  always  be  felt.  The 
internal  condyle  is  the  more  prominent  and  the  less 
rounded  of  the  two.  The  humero-radial  articulation 
forms  a  horizontal  line,  but  the  humero-ulnar  joint  is 
oblique,  the  joint  surfaces  sloping  downwards  and  in- 
wards. Thus  it  happens  that  while  the  external  condyle 
is  only  f  of  an  inch  (18  mm.)  above  the  articular 
line,  the  point  of  the  internal  condyle  is  more  than 
1  inch  (28  mm.)  above  that  part  (Paulet).  From  the 


236  SURGICAL  APPLIED  ANATOMY.  [Chap.  xin. 

obliquity  of  the  joint  surfaces  between  the  ulna  and 
humerus,  it  follows  that  the  fore-arm,  wheii  in  ex- 
tension, is  not  in  a  straight  line  with  the  upper  arm, 
but  forms  with  it  an  angle  that  opens  outwards. 
Thus,  when  traction  is  made  upon  the  entire  upper 
limb  from  the  wrist,  some  of  the  extending  force  is 
necessarily  lost,  and  such  traction,  therefore,  should 
be  applied  from  the  elbow,  as  is  the  usual  practice  in 
reducing  a  dislocation  of  the  shoulder  by  manipulation. 
A  line  drawn  through  the  two  condyles  will  be  at 
right  angles  with  the  axis  of  the  upper  arm,  while  it 
will  fonn  an  angle  with  the  axis  of  the  fore-arm. 
Thus  if  we  look  at  the  upper  arm,  the  two  condyles 
are  on  the  same  level,  whereas,  when  viewed  from  the 
fore-arm,  the  inner  condyle  lies  at  a  higher  level  than 
does  the  external  process. 

The  joint  line  of  the  elbow  is  equivalent  only  to 
about  two -thirds  of  the  width  of  the  entire  line 
between  the  points  of  the  two  condyles.  The  promi- 
nence of  the  condyles  forms  an  excellent  point 
(Kappui-  for  traction  by  encircling  bands  applied 
to  the  limb  above  the  elbow  joint.  At  the  back  of 
the  elbow  the  prominence  of  the  olecraiion  is  always 
to  be  distinctly  felt.  It  lies  nearer  the  internal 
than  the  external  condyle.  In  extreme  extension 
the  summit  of  the  olecranon  is  a  little  above  the  line 
joining  the  two  condyles.  When  the  fore-arm  is  at 
right  angles  with  the  arm,  the  tip  of  the  process  is 
below  the  line  of  the  condyles,  and  in  extreme  flexion 
it  lies  wholly  in  front  of  that  line.  Between  the 
olecranon  and  the  inner  condyle  is  a  depression  that 
lodges  the  iilnar  nerve  and  the  posterior  ulnar 
recurrent  artery. 

To  the  outer  side  of  the  olecranon,  and  just  below 
the  external  condyle,  there  is  a  depression  in  the  skin 
which  is  very  obvious  when  the  limb  is  extended. 
This  pit  is  to  be  seen  even  in  those  who  are  fat,  and 


Chap,  xiii.]  REGION  OF  ELBOW.  237 

also  in  young  children.  In  it  the  head  of  the  radius 
can  be  felt,  and  can  be  well  distinguished  when  the 
bone  is  rotated  in  pronation  and  supination.  The  pit 
corresponds  to  the  hollow  between  the  outer  border 
of  the  anconeus  and  the  muscular  eminence  formed 
by  the  two  radial  extensors  of  the  carpus  and  the 
supinator  longus.  The  highest  point  of  the  bone  that 
can  be  felt  moving  on  rotation  will  correspond  to  the 
radius  immediately  below  the  line  of  the  elbow  joint, 
and  is  a  valuable  guide  to  that  articulation.  The 
upper  limit  of  the  elbow  joint  reaches  a  line  drawn 
between  the  points  of  the  two  condyles.  The  tubercle 
of  the  radius  can  be  felt  just  below  the  head  of  the 
bone  when  the  limb  is  in  the  position  of  extreme 
pronation. 

The  region  of  the  elbow. — The  skin  in  front 
of  the  elbow  is  thin  and  fine,  and  is  readily  excoriated 
by  tight  bandaging  and  by  improperly  applied  splints. 
The  thinness  of  the  skin  allows  the  subjacent  veins  to 
be  easily  seen  through  the  integuments,  but  the 
distinctness  with  which  these  veins  appear  depends 
mainly  upon  the  amount  of  subcutaneous  fat.  In 
the  very  stout  they  may  be  quite  invisible,  and  it 
may  be  difficult  or  impossible  to  render  them  evident 
by  the  usual  means  adopted  in  venesection.  Tillaux 
points  out  that  if  such  people  are  bled  a  pellet  of  fat 
will  often  project  into  the  wound  and  prevent  the 
flow  of  blood. 

The  arrangement  of  the  superficial  veins  in 
front  of  the  elbow,  so  as  to  form  an  M-shaped  figure, 
is  familiar,  but  it  must  be  confessed  that  it  is  by  no 
means  constant  (Fig.  23).  So  far  as  I  have  seen, 
it  would  appear  that  the  precise  M-like  arrangement 
figured  in  most  books  is  only  present  in  about  two- 
thirds,  and  perhaps  in  only  one-half,  of  all  cases. 

The  median  vein  breaks  up  into  the  median 
cephalic  and  median  basilic,  just  to  the  outer  sido 


238 


SURGICAL  APPLIED  ANATOMY.  [Chap  XIIL 


of  the  biceps  tendon,  and,  therefore,  the  latter  vein 
passes  in  front  of  the  tendon,  of  the  brachial  artery 
and  its  veins,  and  of  the  median  nerve.  From 
these  structures  it  is  separated  by  the  bicipital  fascia. 
The  median  basilic  vein  may 
cross  the  brachial  artery  ab- 
ruptly, and  be  comparatively 
free  of  it,  except  at  the  point 
of  crossing,  or  it  may  run  for 
some  distance  quite  in  front 
of  the  artery,  or,  crossing  it 
early,  it  may  lie  parallel  with 
the  vessel,  although  at  a  diffe- 
rent level,  for  the  greater  part 
of  its  course.  As  regards  size, 
the  median  basilic  is  usually 
the  largest  of  these  veins,  the 
median  cephalic  coming  next, 
and  the  median  itself  third, 
while  the  ulnar  and  radial  veins 
are  the  smallest  of  the  series. 
These  veins  are  liable  to  many 
abnormalities,  some  of  the  most 
conspicuous  being  in  cases  where 
the  main  arteries  of  the  part  are 
also  abnormal.  The  deviation 
is  more  usual  in  the  veins  on 
the  radial  than  in  those  on  the 

d,  on  the  radius  points  to        i                •  i           <»  ,1         T      i  rni 
median      cephalic     vein;  Ulliar    Side     of  tll6    lllllb.          lllllS 

e,  radial  vein;  /,  median  •,     •  f         ,,  •>•    •, 
vein;   g,  posterior    uluar  It    IS    COmillOn  tor    the    radial    Of 

the    median    cephalic    veins,  or 

both,  to  be  either  very  defective  or  entirely  absent. 
In  spite  of  the  relation  the  median  basilic  vein 
bears  to  the  brachial  artery,  it  is  nevertheless 
the  vein  usually  selected  in  venesection.  The 
reasons  for  its  selection  are  these  :  it  is  usually 
the  largest  and  most  prominent  of  the  veins,  and 


Pig.  23.— The  Left  Elbow 
from  iu  frout. 

a.  Basilic  vein ;  6,  cephalic 
vein ;  c,  on  the  ulna  points 
to  median  basilic 


Chap.  xin. j  REGION  OF  ELBOW.  239 

the  one  the  nearest  to  the  surface  ;  it  is  also  the 
least  movable  vein,  and  the  one  the  least  subject 
to  variation.  The  bicipital  fascia  forms  an  excel- 
lent protection  to  the  brachial  artery  during 
phlebotomy.  The  density  of"  that  membrane  varies, 
and  depends  mainly  upon  the  degree  of  muscular 
development.  In  thin  subjects  the  median  basilic 
vein  may  receive  pulsations  from  the  subjacent 
artery.  According  to  one  observer,  the  walls  of 
this  vein  are  often  as  thick  as  those  of  the  popliteal 
vein.  The  ulnar,  radial,  and  median  veins  seldom 
yield  enough  blood  on  venesection,  since  they  are 
below  the  point  of  junction  of  the  deep  median 
vein,  and  thus  do  not  receive  blood  from  the  deep 
veins  of  the  limb.  The  brachial  artery  has,  as  may 
be  supposed,  been  frequently  injured  in  bleeding ;  and 
at  the  period  when  venesection  was  very  commonly 
practised,  arterio-venous  aneurisms  at  the  bend  of 
the  elbow  were  not  infrequent.  Since  the  principal 
superficial  lymphatic  vessels  run  with  these  veins, 
and  since  some  of  them  can  scarcely  escape  injury  in 
phlebotomy,  it  follows  that  an  acute  lymphangitis 
is  not  uncommon  after  the  operation,  especially  when, 
the  point  of  the  lancet  being  unclean,  septic  matter  is 
introduced  into  the  wound. 

The  internal  cutaneous  nerve,  which  usually  runs 
in  front  of  the  median  basilic  vein,  may  be  wounded 
in  bleeding  from  that  vessel.  The  injury  to  the 
nerve,  according  to  Tillaux,  may  lead  to  "  traumatic 
neuralgia  of  extreme  intensity,  and  very  chronic." 
A  "  bent  arm "  may  follow  after  venesection,  and 
Mr.  Hilton  believes  this  to  be  often  due  to  injury 
to  the  filaments  of  the  musculo-cutaneous  nerve, 
especially  to  the  inclusion  of  those  filaments  in  a 
scar  left  by  the  operation.  These  peripheral  fibres, 
being  irritated,  the  muscles  supplied  by  the  nerve 
(biceps  and  brachialis  anticus)  are  caused  to  contract 


240  SURGICAL  APPLIED  ANATOMY.  [Chap.  xin. 

by  reflex  action.  Hence  the  bent  arm.  In  one  case 
he  cured  a  bent  arm  following  bleeding  by  resecting 
the  old  scar,  which  on  removal  was  found  to  have 
included  within  its  substance  some  nerve  filaments. 

There  is  a  lymphatic  gland  situated  over  the 
internal  intermuscular  septum  of  the  arm,  and  just 
above  the  internal  condyle.  It  receives  some  of  the 
surface  lymphatics  from  the  inner  side  of  the  fore-arm, 
and  two  or  three  inner  fingers.  In  position,  it  is  the 
lowest  gland  in  the  upper  limb. 

The  bracliial  artery- — In  forcible  flexion  of  the 
limb  the  artery  is  compressed  between  the  muscular 
masses  in  front  of  the  joint,  and  the  radial  pulse  is 
much  diminished  or  even  checked.  Aneurisms  at  the 
bend  of  the  elbow  have  been  treated  by  flexion  of  the 
limb,  that  position  bringing  more  or  less  direct  pressure 
to  bear  upon  the  sac.  In  full  extension  of  the  joint 
the  artery  becomes  flattened  out,  and  the  radial  pulse 
diminished.  In  the  over  extension  possible  with 
fractured  olecranon  the  pulse  may  be  stopped  at  the 
wrist.  Forcible  extension  of  an  elbow  that  has  be- 
come rigid  in  the  bent  position  has  caused  rupture  of 
the  brachial  artery. 

The  ulnar  nerve  is,  from  its  position  at  the 
elbow,  very  liable  to  be  injured.  The  nerve  may  pass 
in  front  of  the  internal  condyle,  and  an  instance  is 
reported  where  the  nerve  slipped  forward  over  that 
eminence  whenever  the  elbow  was  bent  (Quain).  In 
cases  where  an  abnormal  brachial  passes  beneath  a 
supracondyloid  process  the  median  nerve  goes  with 
the  artery.  In  exposing  the  ulnar  nerve  (for  nerve 
stretching,  etc.)  behind  the  elbow  the  nerve  may  be 
found  quite  covered  by  an  occasional  muscle,  the 
epitrochleo-anconeus. 

The  elbow  joint. — The  strength  of  this  joint 
depends  not  so  much  upon  either  ligaments  or  muscles 
a.s  upon  the  coaptution  of  the  bony  surfaces.  The 


Chap  xiiM  REGION  OF  ELBOW.  241 

relations  of  the  olecranon  and  coronoid  process  to  the 
liumerus  are  such  that  in  certain  positions  the  strength 
of  the  joint  is  very  considerable. 

The  elbow,  being  a  pure  hinge-joint,  permits  only  of 
flexion  and  extension.  These  movements  are  oblique, 
BO  that  in  flexion  the  fore-arm  inclines  inwards,  carrying 
the  hand  towards  the  middle  third  of  the  clavicle.  If 
it  were  not  for  the  obliquity  of  the  joint  line  it  would 
be  possible  for  the  hand  to  be  placed  flat  upon  the 
shoulder  of  the  same  side,  but  this  movement  is  only 
possible  after  some  excisions  of  the  joint,  for  in  this 
operation  the  oblique  direction  of  the  articular  surfaces 
is  not  reproduced.  In  extreme  extension  the  ulna  is 
nearly  in  a  straight  line  with  the  humerus  as  regards 
their  lateral  planes,  while  in  extreme  flexion  the  two 
bones  form  an  angle  of  from  30°  to  40°. 

Bursae. — Of  the  bursse  about  the  joint  the  large 
subcutaneous  bursa  over  the  olecranon  is  very 
commonly  found  enlarged  and  inflamed ;  and  when 
inflamed  may  lead  to  extensive  mischief  in  the  limb. 
Its  enlargement  is  favoured  by  certain  employments 
involving  pressure  on  the  elbow ;  thus,  the  disease 
known  as  "  miner's  elbow  "  is  merely  an  enlargement 
of  this  sac.  There  is  a  bursa  between  the  biceps 
tendon  at  its  insertion  and  the  bone,  the  relations  of 
which  to  the  nerves  of  the  fore-arm  are  worth  noting. 
A  case,  for  instance,  is  reported  where  this  bursa 
became  chronically  enlarged,  and  by  pressing  Tipon  the 
median  and  posterior  interosseous  nerves  produced 
loss  of  power  in  the  fore-arm  (Agnew). 

Of  the  ligaments  of  the  elbow  joint  the  anterior 
and  posterior  are  comparatively  thin,  and  the  latter 
especially  soon  yields  to  the  pressure  of  fluid  within 
the  joint  in  disease  of  the  articulation.  The  internal 
lateral  is  the  strongest  and  most  extensive  of  the 
ligaments  of  the  pai-t.  From  its  rigidity,  its  extended 
attachment,  and  the  fact  that  it  serves  to  limit  not 

Q— 4 


242  SURGICAL  APPLIED  ANATOMY.  [Oar.  xni. 

only  flexion  and  extension,  but  alsa  any  attempt 
to  wrench  the  fore-arm  laterally  from  the  arm,  it 
happens  that  it  is  the  ligament  that  suffers  the  most 
often  in  "  sprains  "  of  the  elbow.  As  this  ligament 
is  attached  to  the  whole  length  of  the  inner  border 
of  the  olecranon  it  may  assist  in  preventing  separa- 
tion of  the  fragments  when  that  process  has  been 
fractured. 

Joint  disease. — In  disease  of  this  joint  the 
effusion  first,  and  most  distinctly,  shows  itself  by  a 
swelling  around  the  margins  of  the  olecranon.  This 
is  explained  by  the  facts  that  the  synovial  cavity  is 
here  nearest  to  the  surface,  and  the  posterior  ligament  is 
lax  and  thin.  Some  swelling  is  also  very  soon  noticed 
about  the  line  of  the  radio-humei-al  joint,  and  fluctua- 
tion in  this  situation  serves  to  distinguish  joint  effusion 
from  simple  enlargement  of  thebursa  beneath  the  triceps 
tendon.  Deep-seating  swelling  may  be  noted  about 
the  front  of  the  joint  beneath  the  brachialis  anticus, 
owing  to  the  thinness  of  the  anterior  ligament ;  and 
lastly,  about  the  external  condyle.  The  density  of 
the  internal  ligament  prevents  a  bxilging  of  the 
synovial  membrane  on  the  inner  side.  When  the 
joint  suppurates  the  pus  will  most  easily  reach  the 
surface  by  travelling  upwards  and  backwards  between 
the  humerus  and  the  triceps,  and  the  abscess  points, 
therefore,  very  commonly  at  one  or  other  border 
of  that  muscle.  The  pus  may  escape  beneath  the 
brachialis  anticus  in  front,  and  discharge  itself  near 
the  insertion  of  the  muscle.  When  the  bone  is 
diseased  the  sinuses  form  usually  directly  over  the 
part  attacked.  The  diseased  elbow  tends  to  assume 
the  posture  of  semi-flexion,  and  it  is  interesting  to 
observe  that  that  is  the  position  assumed  by  the  joint 
when  forcible  injections  are  made  into  its  cavity 
(Braune).  The  joint,  in  fact,  holds  the  greatest  amount 
of  fluid  when  it  is  semi-flexed.  As  regards  muscular 


chap,  xni.]        REGION  OF  THE  LLBOIV.  243 

rigidity  of  the  elbow,  due  to  reflex  irritation  from 
disease,  it  is  well  to  note  that  all  the  nerves  of  the 
articulation  supply  muscles  acting  upon  the  joint, 
notably,  the  musculo-spiral  and  musculo-cutaneous. 
The  relation  of  the  ulnar  nerve  to  the  joint  serves  to 
explain  cases  where  severe  pain  has  been  felt  along 
the  fore-arm  and  in  the  fingers,  in  parts  corresponding 
to  the  distribution  of  that  nerve.  The  upper  epiphysis 
of  the  radius  and  the  greater  part  of  the  upper 
epiphyses  of  the  humerns  and  ulna  are  intrasynovial, 
i.e.  come  within  the  capsule  of  the  joint. 

Dislocations  of  the  elbow. — These  are  many, 
and  may  be  thus  arranged.  (1)  Dislocations  of  both 
radius  and  ulna  either  backwards,  outwards,  inwards, 
or  forwards  (in  order  of  frequency).  (2)  Dislocations 
of  the  radius  alone  either  forwards,  backwards,  or 
outwards  (in  order  of  frequency).  (3)  Luxation  of 
the  ulna  alone  backwards. 

As  a  preliminary  it  may  be  convenient  to  note 
some  general  anatomical  considerations  in  connection 
with  these  various  displacements. 

(a)  Antero-posterior  htxations  are  much  more 
common  than  are  lateral  luxations. — Displacements 
in  the  antero-posterior  direction  are  more  common, 
because  the  movements  of  the  joint  take  place  in  that 
direction,  and  the  width  of  the  articular  surface  of  the 
humerus  from  before  backwards  is  comparatively  small. 
On  the  other  hand,  there  is  normally  no  lateral  move- 
ment of  the  elbow,  and  the  width  of  the  articulation 
from  side  to  side  is  considerable.  The  antero-posterior 
ligaments  are  feeble,  while  the  lateral  ligaments  are 
strong,  and  the  joint,  moreover,  receives  more  muscular 
support  at  its  sides  than  it  does  either  behind  or  in 
front.  The  mutual  support  afforded  by  the  bones  to  one 
another  is  weakened  in  the  antero-posterior  direction 
during  certain  movements.  Thus  in  full  flexion  the 
olecranon  has  but  a  feeble  hold  upon  the  humerus, 


244  SURGICAL  APPLIED  ANATOMY.  [Chap. xm. 

while  in  extension  the  hold  of  the  coronoid  process 
upon  that  bone  is  even  less.  In  a  lateral  direction, 
however,  movement  has  but  a  very  slight  effect  upon  the 
support  the  bones  mutually  derive  from  one  another. 

(6)  Both  bones  of  the  fore-arm  are  more  often 
luxated  together  than  is  either  the  radius  alone  or  the 
ul.na  alone.  This  depends  upon  the  powerful  liga- 
mentous  connection  between  the  radius  and  ulna  on 
the  one  hand,  and  the  absence  of  such  connection 
between  the  humerus  and  the  radius  on  the  other. 
In.  the  dead  subject  it  is  not  difficult  to  dislocate  the 
two  bones  of  the  fore-arm,  but  it  is  extremely  difficult 
to  separate  the  radius  from  the  ulna  without  great 
breaking  and  tearing  of  parts. 

(c)  The  commonest    dislocation  of  the   two    bones 
together    is    backwards,    the  rarest   is  forwards. — In 
the  former  instance  the  movement  is  resisted  by  the 
small  coronoid  process,  in  the-  latter  by  the  large  and 
curved   olecranon.       For    like   reasons   the   luxation 
outwards  is  less  rare  than  is  the  displacement  inwards, 
since  the  articular  surface  of  the  humerus   inclines 
downwards  and  inwards  on  the  inner  side,  and  thus 
affords  a  greater  obstacle  in  that  quarter. 

(d)  If  a  single  bone  be  dislocated  it  will  usually  be 
the  radius. — This  follows  from  the  absence  of  reliable 
union  between  that  bone  and  the  humerus,  from  the 
greater  exposure  of  the  radius   ("  the  handle  of  the 
hand ")   to   indirect    violence,   and  from   its   greater 
mobility.     The  luxation  is  iisually  forwards,  due  to 
the  fact  that  the  forms  of  violence  that  tend  most 
often   to  displace  the  bone  tend  also  to  draw  it  for- 
wards. Paulet  asserts  that  the  posterior  part  of  the  an- 
7iular  ligament  is  "  much  more  resistant "  than  is  the 
anterior  part.  The  luxation  of  the  ulna  alone  occurs  in 
the  backward  direction,  for  reasons  that  will  be  obvious. 

Dislocations  of  the  elbow  of  all  kinds  may  be 
partial  or  complete.  More  usually  they  are  complete 


chap,  xiii.j  REGION  OF  ELBOW.  -^ 

when  in  the  antero-posterior  direction,  and  partial 
when  the  luxation  is  lateral. 

Some  more  detailed  notice  may  now  be.  taken 
of  the  only  two  forms  of  dislocation  at  tho  elbow  that 
are  at  all  common. 

(1)  Displacement  of  both  bones  back- 
wards.— This  may  be  effected  during  forced  exten- 
sion. Here  the  point  of  the  olecranon  pressed  against 
the  hunierus  acts  as  the  fulcrum  of  a  lever  of  the 
second  kind,  and  tends  to  tear  the  ulna  fix>m  the 
latter  bone.  The  addition  of  violence  to  the  fore-arm 
iu  a  backward  or  upward  direction  would  effect  the 
actual  displacement.  This  condition  may  be  illustrated 
by  a  fall,  as  in  running,  upon  the  fully  extended 
hand.  The  lesion  may  also  be  produced  by  certain 
violent  wrenchings  of  the  limb.  Malgaigne  maintained 
that  the  particular  kind  of  wrench  most  effectual  in 
producing  luxation  was  a  twisting  inwards  of  tho 
fore-arm  while  the  elbow  was  semi-flexed.  In  this 
way  the  internal  lateral  ligament  was  ruptured,  and 
the  coronoid  process  twisted  inwards  and  downwards 
under  the  humerus,  and  the  bones  thus  displaced  back. 
This  lesion  would  be  difficult  to  effect  while  the  joint 
was  fully  flexed.  In  the  complete  form  the  coronoid 
process  is  opposite  to  the  olecranon  fossa.  It  can 
hardly  occupy  that  hollow  (as  sometimes  described), 
tince  the  connection  of  the  ulna  to  the  radius,  and  the 
projection  of  the  latter  bone  behind  the  outer  condyle, 
would  pi-event  it  from  actually  falling  into  the  fossa. 
The  anterior  and  the  two  lateral  ligaments  are  usually 
.more  or  less  entirely  torn,  while  the  posterior  and  the 
orbicular  ligaments  escape.  The  biceps  is  drawn  over 
the  lower  end  of  the  humerus,  and  is  rendered 
moderately  tense.  The  brachialis  anticus  is  much 
stretched  and  often  torn.  The  anconeus  is  made  veiy 
tense.  Both  the  median  and  vlnar  nerves  may  b« 
severely  stretched. 


246  SURGICAL  APPLIED  ANATOMY,  [chap.  xm. 

Dislocation  of  the  radius  forwards.— This 
may  be  due  to  direct  violence  to  the  bone  from  behind, 
or  to  extreme  pronation,  or  to  falls  upon  the  extended 
and  pronated  hand.  The  anterior,  external,  and 
annular  ligaments  ai%e  torn.  There  would  seem  to  be 
a  lack  of  evidence  in  support  of  Hamilton's  statement 
that  "  sometimes  the  anterior  and  external  lateral 
are  alone  broken,  the  annular  ligament  being  then 
sufficiently  stretched  to  allow  of  the  complete  disloca- 
tion." The  biceps  being  relaxed,  the  pronators  act, 
and  the  limb  is  either  pronated.  or  assumes  a  position 
midway  between  pronation  and  supiiiation.  Some 
stretching  of  the  supiiiator  brevis  would  probably 
modify  the  amount  of  pronation.  A  difficulty  in  the 
reduction  is  often  due  to  the  torn  annular  ligament 
coming  between  the  head  of  the  radius  and  the 
humeral  condyle. 

Sprain  ol  the  elbow. — Mr.  J.  Hutchinson, 
Jun.,  has  shown  that  in  young  children,  under  five 
years,  forcible  traction  of  the  limb  in  the  supinated 
position  may  cause  the  radius  to  slip  downwards,  away 
from  the  orbicular  ligament,  which  is  displaced  up- 
wards. Flexion  of  the  elbow  in  the  pronated  position 
restores  the  ligament  to  its  normal  position.  It  is 
clear  that  this  displacement  is  the  anatomical  basis 
of  the  common  sprain  of  the  elbow  met  with  in  young 
children,  and  usually  due  to  violent  traction  of  the 
hand. 

Fractures  of'the  lower  end  of  the  liuincrus. 
— These  are  :  (1)  A  fracture  just  above  the  condyles  ; 

(2)  "the   T-shaped    fracture"    involving   the   joint; 

(3)  fractures  of  the  internal,  and  (4)  of  the  external 
condyle  ;  (5)  fracture  of  the  internal  epicondyle  ;  and 
(6)  separation  of  the  lower  epiphysis. 

All  these  fractures  are  more  common  in  the 
young. 

1.  The  fracture  "  at  the  base  of  the  condyles,''  as 


Chap,  xin.]  REGION  OF  ELBOW.  247 

it  is  sometimes  called,  is  usually  situate  a  little  above 
the  olecranon  fossa,  where  the  humeral  shaft  begins 
to  expand.  It  is  commonly  transverse  from  side  to 
side,  and  oblique  from  behind  downwards  and  forwards. 
It  is  generally  the  result  of  a  blow  inflicted  upon 
the  extremity  of  the  elbow.  Probably  the  tip  of 
the  olecranon  driven  sharply  against  the  bone  acts 
like  the  point  of  a  wedge,  and  takes  an  important 
share  in  the  production  of  the  fracture.  The  lower 
fragment,  together  with  the  bones  of  the  fore-arm,  is 
generally  carried  backwards  by  the  triceps,  and 
upwards  by  that  muscle,  the  biceps,  and  the  brachialis 
anticus.  The  median,  or  ulnar  nerves,  especially  the 
latter,  may  be  severely  damaged. 

2.  The  "T-shaped  fracture  "  is  but  a  variety  of  the 
lesion    just    noted.     In    addition    to    the    transverse 
fracture  above  the  condyles,  there  is  also  a  vertical 
fracture  running  between  the  two  condyles  into  the 
joint.     The  lower  fragment  is  thus  divided  into  two 
parts.       The  displacement  is  the  same.      The  fracture 
is  very  usually  due  to  a  fall  upon  the  bent  elbow,  and 
here  possibly  also  the  tip  of  the  olecranon  acts  as 
a  wedge,  producing  the  transverse  fracture,  while  the 
prominent   ridge    along    the    middle    of    the   greater 
sigmoid  cavity,  acting  as  a    second  wedge,  produces 
the  vertical  fracture  into  the  joint. 

3,  4,  and  5,    For  surgical  purposes  it  is  well  to 
limit    the    term    "  condyle "    to     such    parts    of    the 
extremity  of  the  humerus  as  are  within  the  capsule, 
and  the  term  "  cpicondyle  "  to  such  parts  of  the  lower 
projections  of  the  bone  as  are  without  the  joint. 

In  the  so-called  fracture  of  the  inner  condyle 
the  line  of  separation  generally  commences  about  half 
an  inch  above  the  tip  of  the  epicondyle  (and,  therefore, 
outside  the  joint),  and  running  obliquely  outwards 
through  the  olecranon  and  coronoid  fossae,  enters  the 
articulation  through  the  centre  of  the  trochlear  surface 


248  SURGICAL  AITLICD  ANATOMY.  [Ci..-^.  \m. 

(Hamilton).  The  fragment  is  often  displaced  a  little 
upwards,  backwards,  and  inwards,  the  ulna  going 
with  it. 

In  the  fracture  of  the  external  condyle  the  line 
commences  also  above  the  epicondyle  and  outside 
the  joint,  and  running  downwards  enters  the  joint 
usually  between  the  trochlear  surface  and  the  surface 
for  the  radius.  The  displacement  is  trifling  and 
inconstant. 

On  account  of  its  insignificant  size,  a  fracture 
of  the  external  epicondyle  is  scarcely  possible. 
Fractures  of  the  inner  epicondyle  are,  however,  quite 
common,  the  joint  remaining  free.  This  epicondyle 
exists  as  a  distinct  epiphysis,  which  unites  at  the  age 
of  eighteen,  and  which  at  any  time  before  that  age 
may  be  separated  from  the  bone  by  direct  injury  or 
muscular  violence.  Owing  to  the  dense  aponeurotic 
fibres  that  cover  the  part,  much  displacement  of  the 
fragment  is  uncommon.  When  displacement  exists, 
it  is  in  the  general  line  of  the  common  flexor  muscles 
that  arise  from  the  tip  of  the  process. 
-  6.  The  lower  epiphysis.  The  line  of  this  epiphysis 
is  nearly  horizontal,  running  across  the  bone  just 
above  the  tips  of  the  two  condyles.  It  presents 
several  ossific  nuclei,  which,  with  the  exception  of  the 
nucleus  for  the  inner  epicondyle,  unite  with  the 
main  bone  about  the  seventeenth  year.  Thus,  after  the 
age  of  seventeen  the  growth  of  the  bone  must  depend 
upon  the  activity  of  the  upper  epiphysis,  which  does  riot 
unite  until  twenty.  Excision  of  the  elbow,  therefore, 
after  the  sixteenth  or  seventeenth  year,  will  not  be 
followed  by  arrest  of  development  in  the  limb,  even  if 
tho  epiphyseal  line  has  been  transgressed  by  the  saw. 
Several  cases  are,  however,  reported  of  marked  arrest 
of  growth  in  the  limb  following  upon  injuries  to  the 
lower  epiphysis  before  the  sixteenth  year,  and  to  the 
upper  epiphjsis  before  twenty.  Since  the  epipliysea] 


Chap,  xiii.]  REGION  OF  ELBOW.  249 

line  is  almost  wholly  within  the  capsule,  it  follows 
that  but  little  displacement,  other  than  a  slight 
movement  backwards,  is  consequent  upon  the  separa- 
tion of  the  mass. 

Fractures  of  the  olecranoii  are  commonly  clue 
to  direct  violence,  and  in  a  few  cases  to  severe  indirect 
violence  applied  to  the  lower  end  of  the  humerus  or 
upper  end  of  the  ulna.  Instances  of  fracture  by 
muscular  action  are  few,  and  open  to  some  question. 
The  fracture  is  most  commonly  met  with  about  the 
middle  of  the  process,  just  where  it  begins  to  be 
constricted,  and  is  usually  transverse  in  direction.  The 
amount  of  displacement  effected  by  the  triceps  varies, 
and  depends  upon  the  extent  to  which  the  dense 
periosteum  about  the  process  and  the  ligaments  that 
are  attached  to  it  are  torn.  The  olecranon  is  developed 
mainly  from  the  shaft  of  the  ulna.  There  is  a  small 
epiphysis,  however,  at  the  summit  of  the  process  which 
joins  the  rest  of  the  olecranon  at  the  age  of  seventeen. 
It  is  a  mere  shell  of  bone.  In  young  subjects  this 
scale-like  epiphysis  may  be  separated  by  violence,  or 
the  cartilaginous  olecranon  may  be  dissevered  from  the 
rest  of  the  bone.  The  common  fracture  of  the  adult 
olecranon  does  not  follow  the  epiphyseal  line. 

Fraetiire  of  the  coronoid  process  is  an 
extremely  rare  accident.  It  is  impossible  to  under- 
stand how  the  process  can  be  torn  off  by  the  action 
of  the  brachialis  anticus,  as  some  maintain,  since  that 
muscle  is  inserted  rather  into  the  ulna  at  the  base  of 
the  projection,  than  into  the  process  itself.  Nor  can 
it  be  separated  as  an  epiphysis,  as  supposed  by  others, 
since  it  does  not  exist  as  such. 

Fractures  of  the  head  or  neck  of  the  radius 
are  rare,  and  occur  usually  with  dislocation  or  other 
severe  injury.  The  head  is  commonly  found  split  or 
starred,  and  the  lesion,  if  limited  to  the  head,  could 
hardly  be  diagnosed.  The  upper  epiphysis  of  the 


250  SURGICAL  APPLIED  ANATOMY,  ici^p.  xm. 

radius  is  entirely  within  the  limits  of  the  annular 
ligament,  and  could  scarcely  be  separated  in  a  simple 
lesion.  It  is  a  mere  disc  of  cartilage  joining  the  shaft 
at  the  age  of  seventeen.  When  the  neck  is  broken 
the  upper  end  of  the  lower  fragment  is  drawn  well 
forwards  by  the  biceps  muscle. 

Resection  oil  lie  elbow  may  be  performed  in 
many  ways.  In  all  procedures  there  is  danger  of 
injuring  the  ulnar  nerve,  and  some  little  difficulty 
often  in  clearing  the  prominent  internal  condyle.  If 
the  knife  be  kept  close  to  the  bone,  no  vessel  of  any 
magnitude  should  be  divided.  The  muscles  most  dis- 
turbed are  the  triceps,  anconeus,  supinator  brevis, 
extensor  carpi  ulnaris,  extensor  carpi  radialis  brevior, 
and  brachialis  anticus.  It  is  most  important  to  pre- 
serve the  periosteum  over  the  olecranon,  so  that  the 
triceps  may  still  have  some  attachments  to  the  fore- 
arm. It  is  never  necessary  to  divide  the  insertion  of 
the  brachialis  anticus,  still  less  of  the  biceps,  although 
some  few  fibres  of  the  former  muscle  may  be  separated 
in  removing  the  upper  surface  of  the  ulna.  By  the 
subperiosteal  method  the  periosteum  is  carefully  peeled 
off  from  all  the  parts  to  be  resected,  and  is  preserved. 
By  this  means  the  triceps  retains  a  hold  upon  the 
ulna,  and  the  restoration  of  the  joint  is  more  complete. 
The  functions  of  the  joint  may  be  well  restored  after 
resection,  especially  when  performed  by  the  subperios- 
teal method,  but  it  would  appear  that  after  110  method 
are  the  anatomical  details  of  the  joint  reproduced. 
Thus,  in  a  successful  case,  the  new  joint  will  assume 
the  biuialleolar  form,  and  will  resemble  the  ankle 
rather  than  the  elbow  joint.  The  humerus  throws 
out  two  malleoli  on  the  sites  of  the  normal  condyles, 
and  in  the  concavity  between  them  the  ulna  and  radius 
are  received.  Between  the  ulna  and  the  humerus 
new  ligaments  form,  and  a  new  annular  ligament  for 
the  radius  is  also  developed. 


CHAPTER     XIV. 

THE    FORE-ARM. 

Surface  anatomy.  —  At  its  upper  half,  ami 
especially  in  its  upper  third,  the  limb  is  much  wider 
in  its  transverse  than  in  its  anteroposterior  diameter. 
A  horizontal  section  through  this  part  will  show  a 
cut  surface  that  is  somewhat  oval  in  outline,  and 
is  at  the  same  time  flattened  in  front  and  more 
convex  behind.  This  outline  is  best  seen  in  muscular 
subjects,  and  depends  chiefly  upon  the  development  of 
the  lateral  masses  of  muscle  that  descend  from  the 
condyles.  In  the  non-muscular,  the  limb,  even  in  its 
highest  parts,  tends  to  assume  a  rounded  rather  than 
an  oval  outline.  In  women  and  children,  also,  the  limb 
is  round,  owing  to  the  comparatively  slight  develop- 
ment of  the  lateral  muscular  masses,  and  to  the 
accumulation  of  fat  on  the  front  and  back  of  the  limb. 
The  posterior  surface  of  the  fore-arm  in  a  vigorous 
subject  presents  along  its  outer  border  a  prominence 
formed  by  the  supinator  lougus  and  the  two  radial 
extensors,  which  become  tendinous  below  the  centre 
of  that  border.  On  the  lower  third  of  this  edge  is  a 
slight  eminence,  directed  obliquely  downwards,  out- 
wards, and  forwards,  and  due  to  the  crossing  of  the 
extensors  of  the  thumb.  In  the  middle  of  the  pos- 
terior surface  is  another  elevation,  running  down 
from  the  outer  condyle,  and  formed  mainly  by 
the  extensor  communis.  To  the  inner  side  of  this 
eminence  is  a  groove,  well  seen  in  the  very  muscular, 
that  indicates  the  posterior  border  of  the  ulna.  The 
ulua  is  subcutaneous  throughout  its  entire  extent,  and 


252  ZURC/CAL  APPLIED  ANATO.MV.   [Ch.>?.  \iv. 

can  be  readily  examined.  The  upper  half  of  the  radius 
is  too  deeply  placed  to  be  well  made  out,  but  the 
lower  half  of  the  bone  can  be  easily  felt  beneath  the 
skin.  The  course  of  the  radial  artery  is  represented 
by  a  line  drawn  from  the  outer  border  of  the  bicepa 
tendon  at  the  bend  of  the  elbow  to  the  narrow 
interval  between  the  scaphoid  bone  and  the  extensor 
tendons  of  the  thumb.  The  middle  and  lower  thirds 
of  the  ulnar  artery  follow  a  line  from  the  inner  con- 
dyle  to  the  radial  side  of  the  pisiform  bone.  The 
upper  third  would  be  represented  by  a  line  drawn  from 
the  middle  of  the  bend  of  the  elbow  to  meet  the  first 
line  at  the  junction  of  the  upper  and  middle  thirds  of 
the  inner  border  of  the  fore-arm.  Such  a  line  would 
be  slightly  curved,  with  its  concavity  outwards.  The 
tendons,  etc.,  that  can  be  demonstrated  at  the  lower 
extremity  of  the  fore-arm  will  be  considered  in  the 
description  of  the  wrist. 

Vessels. — It  is  well  to  note  the  very  free  anasto- 
moses that  exist  along  the  greater  part  of  the  limb 
between  the  ulnar  and  radial  arteries.  This  fact  was 
illustrated  by  a  case  under  my  care,  some  time  ago,  in 
the  London  Hospital.  A  seaman  had  inflicted  upon 
his  left  fore-arm  three  deep  transverse  wounds  across 
the  front  of  the  limb  with  a  sharp  knife.  The  wounds 
were  about  1^  inches  apart.  The  radial  artery  was 
divided  in  each  of  the  wounds,  and  that  vessel,  there- 
fore, presented  six  cut  ends.  It  would  appear  to  be 
sufficient  to  ligature  the  proximal  and  distal  ends  of 
the  wounded  vessel,  and  to  leave  the  two  isolated 
portions  of  the  artery,  each  about  1^  inches  in  length, 
alone.  I  applied  ligatures  to  five  of  the  divided  ends, 
leaving  the  lower  end  of  the  upper  isolated  piece  of 
the  artery  untied,  and  watched  the  effect.  During  the 
course  of  the  day,  when  the  man  had  rallied  from  the 
profound  faintness  due  to  the  great  loss  of  blood  he 
had  experienced,  copious  bleeding  took  place  from  this 


Chap.  XIV.] 


THE  FORE-ARM. 


253 


single  unsecured  end  of  the  vessel,  and  it,  of  course, 
had  also  to  be  tied. 

There  is  a  singular  absence  of  large  blood-vessels 
or  nerves  along  the  posterior  aspect  of  the  fore-arm, 
and  it  is  significant  that  this  is  the  aspect  of  the  limb 
most  exposed  to  injury.  For  a  hand's-breadth  below 
the  olecraiion  there  is  almost  an  entire  absence  of 
superficial  veins. 

The  median  nerve  passes  between  the  two 
heads  of  the  pronator  teres,  and  may  possibly  be  com- 
pressed by  that  muscle 
when  in  vigorous  ac- 
tion. In  this  way 
may  be,  perhaps,  ex- 
plained the  cramp  on 
the  flexor  side  of  the 
limb  that  sometimes 
occurs  after  certain 
violent  exercises.  The 
amount  of  muscular 
tissue  in  the  deep 
head  of  the  muscle 
varies  considerably. 

The bones  of  the 
fore-arm.  —  Trans- 
verse sections  of  tho 
limb  at  various  levels 
show  that  the  radius 
and  ulna  are  in  all 
parts  nearer  to  the 
posterior  than  the  an- 
terior aspect  of  the 
extremity  (Figs.  24 
and  25).  This  relation  is  the  more  marked  the  higher 
up  the  section.  The  two  bones  are  nearest  to  the  centre 
of  the  limb,  about  the  lower  end  of  the  middle  third. 
At  the  upper  part  of  the  fore-arm  the  muscles  are 


Fig.  24. — A  Transverse  Section  through 
the  middle  of  the  Fore-arm  (Braime). 

a,  Radius;  6,  ulna;  c,  gupinator  lon.cus ;  d, 
flexor  longus  pollicis :  e,  flexor  carpi  radi- 
alis ;  /,  palmans  lonpus  ;  g,  flexor  etiblimis 
dipitorum  ;  ft,  flexor  carpi  ulnaris  ;  ?',  flexor 
prufundus  digitorum  ;  k,  extensor  carpi 
ulnaris  ;  (,  extensor  indicis  ;  m,  extensor 
minimi  digiti ;  n,  extensor  eoinniunis  dijri- 
toruin ;  o,  extensor  ossis  and  extensor 
secundi  internodii  pollicig ;  q,  extensor 
carpi  radialis  brevior ;  r,  extensor  carpi 
radialis  longior ;  ».  pronator  radii  teres ; 
1,  radial  vessels  and  nerve  ;  2,  ulnar  vessels 
and  nerve. 


254  SURGICAL  APPLIED  ANATOMY.  [Chap.  xiv. 

found  mainly  at  the  sides  and  in  front.  The  lower  the 
section  proceeds  down  the  limb,  the  less  will  the  bones 
be  covered  at  the  sides,  and  the  more  equally  will  the 
soft  parts  be  found  distributed  about  the  anterior 
and  posterior  aspects  of  the  limb.  It  will  be  noticed 
that  where  one  bone  is  the  most  substantial  the  other 
is  the  most  slender,  as  near  the  elbow  and  wrist ;  and 
that  it  is  about  the  centre  of  the  limb  that  the  two 
are  most  nearly  of  equal  Strength.  The  proximity 
of  the  two  bones,  and  especially  of  the  ulna,  to  the 
posterior  aspect  of  the  limb  permits  them  to  be  easily 
examined  from  that  surface,  while  it  is  from  the 
same  aspect  that  resections  and  other  operations  upon 
the  bones  are  most  readily  performed.  It  will  be 
understood,  moreover,  that  in  compound  fractures, 
due  to  penetration  of  fragments,  the  wound  is  more 
usually  on  the  posterior  aspect  of  the  limb. 

The  important  movements  of  pronation  and  supi- 
nation  take  place  between  these  bones,  and  round  an 
axis  corresponding  to  a  line  drawn  through  the  head 
of  the  radius,  the  lower  end  of  the  ulna,  and  the 
rrietacarpal  bone  of  the  ring-finger.  Pronation  is 
i!  dnly  checked  by  the  lower  and  middle  parts  of  the 
interosseous  membrane,  the  posterior  radio-ulnar  liga- 
ment, the  inner  part  of  the  posterior  ligament  of  the 
wrist,  and  the  opposition  of  the  bones.  Supina- 
tion  is  chiefly  limited  by  the  lowest  fibres  of 
the  interosseous  membrane,  the  anterior  radio-ulnar 
ligament,  and  the  internal  lateral  ligament  of  the 
wrist.  "The  chief  influence  in  checking  supination 
is  not  to  be  found  in  ligament  at  all,  but  in  the  con- 
tact of  the  posterior  edge  of  the  sigmoid  cavity  of  the 
radius  with  the  tendon  of  the  extensor  carpi  ulnaris, 
as  it  lies  in  the  groove  between  the  styloid  process  and 
the  round  head  of  the  ulna  "  (H.  Morris).  Of  the  two 
movements,  supination  is  the  more  powerful.  This 
is  illustrated  in  many  ways.  In  using  a  screw-driver 


Chap,  xiv.]  THE  FORE- A  KM.  255 

or  a  gimlet  the  movements  of  pronation  and  supination 
are  conspicuously  involved,  but  the  main  force  is 
applied  during  supination.  It  is  significant  that  the 
thread  of  a  corkscrew  is  so  turned  that  it  shall  be  in- 
serted by  supination  rather  than  by  pronation. 

The  only  position  in  which  the  two  bones  are 
parallel  to  one  another  is  in  the  mid-position  between 
pronation  and  supination.  It  is  in  this  posture  only 
that  the  interosseous  membrane  is  uncoiled  throughout. 
Hence  the  selection  of  this  position  in  the  adjustment 
of  most  fractures  of  the  fore-arm.  The  interosseous 
space  is  an  irregular  ellipse,  a  little  larger  below  than 
above.  It  is  narrowest  in  full  pi'onation,  widest  in 
supination,  and  nearly  as  wide  in  the  mid-position, 

It  may  be  noted  that  the  oblique  ligament  tends 
to  resist  forces  that  would  drag  the  radius  away  from 
the  humerus,  and  takes  the  place  and  the  function  of 
a  direct  ligament,  passing  from  the  humerus  to  the 
radius,  while  the  interosseous  membrane,  from  the 
obliquity  of  its  fibres,  makes  the  ulna  take  a  share  in 
the  strain  put  upon  the  radius  when  that  bone  is 
forced  upwards,  as  in  resting  on,  or  pushing  with,  the 
palm. 

Fractures  of  the  fore-arm. — The  two  bones 
are  more  often  broken  together  than  is  either  the 
radius  or  the  ulna  alone.  The  radius,  when  broken 
alone,  is  usually  fractured  by  indirect  violence,  since 
it  receives  more  or  less  entirely  all  shocks  transmitted 
from  the  hand.  The  ulna,  on  the  contrary,  is  more 
often  broken  by  direct  violence,  it  being  the  more  super- 
ficial and  exposed  of  the  two  bones.  For  example,  in 
raising  the  arm  to  ward  off  a  blow  from  the  head,  the 
ulna  becomes  uppermost.  When  the  two  bones  are 
broken  together,  the  violence  may  be  direct  or  indirect. 
Malgaigne  reports  a  case  where  both  bones  were  broken 
by  muscular  violence  in  a  patient  while  shovelling 
earth.  Here  the  bones  probably  were  broken  between 


256  SI'KGICAL  APPLIED  ANATOMY.  [Chap,  xiv, 

the  two  opposed  forces  represented  by  the  biceps  and 
brachialis  anticus  above  and  the  weight  of  the  loaded 
shovel  in  the  hand  below.  When  both  bones  are 
broken  and  the  fractures  are  oblique,  shortening  may 
be  produced  by  the  united  action  of  the  flexors  and 
extensors.  The  displacement  varies  greatly,  and  de- 
pends rather  upon  the  direction  of  the  violence  than 
upon  muscular  action.  Thus  Hamilton  says  :  "  I  have 
seen  the  fragments  deviate  slightly  in  almost  every 
direction."  If  union  be  delayed,  the  delay  is  usually 
in  the  radius,  since  it  is  the  more  mobile  of  the  two 
bones.  When  the  radius  alone  is  broken  (1)  between 
the  insertions  of  the  biceps  and  pronator  teres,  the 
upper  fragment  is  flexed  by  the  biceps  and  fully 
supinated  by  that  muscle  and  the  small  supinator. 
The  lower  fragment  will  be  pronated  by  the  two  pro- 
nators,  and  drawn  in  towards  the  ulna  by  means 
of  those  muscles.  If  such  a  fracture  be  put  up 
with  the  hand  midway  between  the  prone  and  supine 
position,  the  following  evils  result :  the  upper  frag- 
ment is  fully  supinated  by  the  muscles ;  the  lower 
fragment  is  placed  in  the  mid-position  by  the  splints. 
It  follows  that  the  proper  axis  of  the  bone  is  not  repro- 
duced, and  the  use  of  the  biceps  and  supinator  brevis 
as  supinators  is  entirely  lost.  Thus  patients  so  treated 
usually  recover  with  great  loss  in  the  power  of 
supination ;  and  to  avoid  this  ill  result,  it  is  advised 
to  put  the  limb  up  in  full  supination,  so  that  the  two 
fragments  may  unite  in  their  proper  axis,  the  upper 
fragment  being  supinated  by  the  muscles,  the  lower 
by  the  splints.  (2)  When  the  fracture  is  between  the 
insertions  of  the  two  pronators,  the  upper  fragment 
may  be  carried  a  little  forwards  by  the  biceps  and  pro- 
nator teres,  and  drawn  towards  the  ulna  by  the  latter 
muscle.  The  bone  will  probably  be  in  the  mid-position, 
the  two  supinators  (biceps  and  supinator  brevis) 
attached  to  the  fragment  being  more  or  loss 


Chap,  xiv.]  THE  FORE-ARM.  257 

neutralised  by  the  pronator  that  is  also  connected 
with  it.  The  lower  fragment  will  be  adducted  to 
the  ulna  by  the  pronator  quadratus,  and  its  upper 
end  will  be  still  further  tilted  towards  that  bone 
by  the  action  of  the  supinator  longus  upon  the 
styloid  process.  When  the  ulna  is  broken  alone, 
as,  for  example,  about  its  middle,  the  upper  frag- 
ment may  be  drawn  a  little  forwards  by  the 
brachialis  anticus,  while  the  lower  fragment  will  be 
carried  towards  the  radius  by  the  pronator  quad- 
ratus. 

The  displacement,  however,  in  all  cases  is  in- 
fluenced as  much  by  the  direction  of  the  violence  as 
by  the  action  of  muscles.  When  the  fragments, 
after  fracture  of  one  or  of  both  bones,  fall  in  towards 
one  another,  so  as  to  meet  across  the  interosseous 
space,  attempts  are  sometimes  made  to  separate  the 
broken  ends  and  to  preserve  the  integrity  of  the  space 
by  the  use  of  graduated  pads.  These  pads,  however, 
if  supplied  with  sufficient  force  to  separate  the  frag- 
ments, will  probably  compress  one  or  both  of  the 
arteries  of  the  limb,  and  cause  great  distress  by 
pressure  upon  the  median  nerve. 

The  fact  that  the  bulk  of  the  venous  blood  of  the 
fore-arm  is  returned  by  surface  veins  may  explain  the 
ready  occurrence  of  severe  oedema  in  the  limb  when 
fractures  are  treated  with  improperly-applied  splints 
or  bandages.  Since  the  arteries  also  can  be  readily 
affected  by  pressure,  it  follows  that  gangrene  of  the 
limb,  as  a  result  of  improper  treatment,  is  more  com- 
mon after  fracture  of  the  fore-arm  than  after  fracture 
in  any  other  part. 

Amputation  of  the  fore-arm. — In  amputa- 
tion of  the  fore-arm  by  double  transfixion  flaps,  at 
about  the  upper  part  of  ,the  middle  third  the  parts 
would  be  cut  in  the  following  manner  :  On  the  face  of 
the  anterior  flap  would  be  seen  from  without  inwards 

R— 4 


SURGICAL  APPLIED  ANATOMY.  [Chap.  xiv. 


the  supinator  longus  (cut  the  whole  length  of  the  flap), 
then  the  flexor  sublimis  (cut  to  a  like  extent),  and, 

lastly,  the  flexor  carpi  ul- 
iiaris.  Between  the  supi- 
nator longus  and  the  flexor 
sublimis  the  divided  end  of 
the  pronator  teres  is  seen  ; 
and  between  the  flexor  sub- 
limis and  the.  skin  would 
^  lie  the  flexor  carpi  radiulis 
and  the  palmaris  longus. 
The  latter  would  appear  as 
Section  a  tendon  at  the  inner 
border  of  the  flap.  In  the 

a,  Radius;  b,  ulna;  c,  supinator  longus;     &nSle      between      the      two 


fuudusdigitorumU.prouatorquad-       f    .\ 

ratus;   fc,  extensor  carpi   ulnaris;  ul    tuo 

1,  extensor   indicia;    in,   extensor  ^.V  Brt<l  m  4Wvn+ /\f  *tta  nlna 

minimi   digiti ;    n,  extensor  com-  CIS,  ailCl  111  IlGHt  Ot  U16  Ulna, 

munis  digUonim;   of  extensor  se-  +!,„    flpv-ni-    nrnfn  n  rl  1 1 «      tVm 

cundiinteraodii  pollicis;  p,  exteu-  lne    n6XOl    prOIUliailS,     U1O 

eor  primi   interuodii    pollicis;    q,  lnff f,r  r-iit  innnli  flip  Inn trpv 

extensor  carpi  radialis  brevior  ;  r,  I»W»T  CUt  lllUCH  tne  longer, 

extensor  carpi  radiali^  longior,  with,  Oni^ti   r>lnca   +n   flip    vjrliiic 

in  front  of  it,  the  extensor  ossis  VjUluB   C1OS6   tO   T/UC    raCtlUS, 

metacarpi  pollicis;  1, radial  vessels;  j,,.rl  fnrtl1pT^lr>«^  nari-  lipliind 

2,  ulnar  vessels ;  3,  median  nerve.  auui  3  mobt  pal  o  Ut 

it,  would  be  the  lowest  part 

of  the  small  supinator,  while  behind  the  ulna  would 
be  the  cut  fibres  of  the  upper  end  of  the  extensor 
ossis.  On  the  face  of  the  posterior  flap  would  be 
seen  from  without  inwards  the  extensor  carpi  radialis 
longior  and  brevior,  the  extensor  communis,  the  ex- 
tensor of  the  little  finger,  and  the  extensor  carpi 
ulnaris.  The  radial  artery  will  run  the  whole  length 
of  the  anterior  flap,  and  be  cut  near  its  outer  border 
to  the  inner  side  of  the  supinator  longus.  The  ulnar 
artery  will  be  cut  shorter,  will  be  in  front  of  the  bone, 
and  between  the  flexor  sublimis  and  flexor  profundus. 
The  anterior  iiiterosseous  vessels  will  be  divided  in»- 
vnediately  in  front  of  the  iiiterosseous  membrane. 


chap,  xv.)         THE   WRIST  AND  HAND.  259 

The  posterior  interosseous  vessels  will  be  cut  long, 
and  will  be  found  between  the  superficial  and  deep 
muscles. 

Fig.  25  shows  the  relation  of  the  parts  as  they 

would  be  cut  in  a  circular  amputation  of  the  limb 
through  the  lower  third. 


CHAPTER  XV. 

THE    WRIST   AND    HAND. 

Surface  anatomy. — The  following  structures 
can  be  made  out  about  the  wri&t:  Commencing  at 
the  outer  side,  the  lower  extremity  and  styloid  process 
of  the  radius  can  be  well  denned.  The  bone  is  here 
superficial  in  front  and  behind.  The  styloid  process 
lies  more  anteriorly  than  does  the  corresponding 
process  of  the  ulna,  and  also  descends  about  half  an 
inch  lower  down  the  limb.  The  outer  surface  of  the 
radius  at  the  wrist  is  crossed  by  the  tendons  of  the 
extensor  ossis  metacarpi  and  extensor  brevis  pollicis. 
These  are  very  distinct  when  the  thumb  is  abducted, 
and  the  slit-like  interval  between  the  two  can  be 
felt.  About  the  centre  of  the  front  of  the  wrist  is 
the  palmaris  longus  tendon,  which  is  usually  the  most 
conspicuous  of  the  tendons  on  this  aspect  of  the 
joint.  It  is  rendered  most  prominent  when  the 
wrist  is  a  little  flexed,  the  fingers  and  thumbs  ex- 
tended, and  the  thenar  and  hypothenar  eminences  as 
much  approximated  as  possible.  A  little  to  its  outer 
side  is  the  larger  but  less  prominent  tendon  of  the 
flexor  carpi  radialis.  In  the  narrow  groove  between 
these  two  tendons  lies  the  median  nerve,  and  on  the 
radial  side  of  the  flexor  carpi  radialis  is  the  i-adial 


260  SURGICAL  APPLIED  ANATOMY,    [u^p.  xv. 

artery.*  Towards  the  inner  border  of  the  wrist  the 
flexor  carpi  ulnaris  tendon  is  evident,  descending  to 
the  pisiform  bone.  It  is  rendered  most  distinct  when 
the  wrist  is  slightly  flexed,  and  the  little  finger  pressed 
forcibly  into  the  palm.  In  the  hollow  which  this 
posture  produces  between  the  last-named  tendon  and 
the  palrnaris  longus  lie  the  flexor  sublimis  tendons,  and 
just  to  the  radial  side  of  the  flexor  carpi  ulnaris  the 
pulsations  of  the  ulnar  artery  can  be  felt.  Beneath 
the  thin  skin  in  front  of  the  wrist  a  part  of  the  plexus 
of  veins  can  be  seen  that  end  in  the  median  and 
anterior  ulnar  trunks. 

At  the  back  of  the  wrist  the  following  tendons  can 
be  readily  distinguished  from  without  inwards  :  the 
extensor  longus  pollicis  (extensor  secundi  internodii), 
the  extensor  communis,  and  the  extensor  carpi  ulnaris. 
Of  these,  the  most  prominent  is  the  first-named.  It 
is  rendered  most  distinct  when  the  thumb  is  forcibly 
abducted  and  extended.  The  tendon  leads  up  to  a 
small  but  prominent  bony  elevation  on  the  back  of 
the  radius  that  marks  the  outer  border  of  the  osseous 
groove  for  its  reception.  This  tendon,  when  it  reaches 
the  radius,  points  to  the  centre  of  the  posterior  surface 
of  that  bone,  and  indicates  also  roughly  the  position 
of  the  interval  between  the  scaphoid  and  semilunar 
bones.  The  lower  end  of  the  ulna  is  very  distinct. 
When  the  hand  is  supine,  its  styloid  process  is  exposed 
at  the  inner  and  posterior  aspect  of  the  wrist  to  the 
inner  side  of  the  extensor  carpi  ulnaris.  In  prona- 
tion,  however,  the  process  is  rendered  less  distinct, 
while  the  head  projects  prominently, 011  the  posterior 
part  of  the  wrist,  and  is  found  to  lie  between  the 
tendons  of  the  extensor  carpi  ulnaris  and  extensor 
minimi  digiti. 

*  Sometimes  the  superficialis  volae  arises  higher  and  is  larger 
than  usual.  It  then  runs  by  the  side  of  the  radial  in  front  of  the 
wrist,  and,  giving  additional  volume  to  the  pulse,  has  been  the 
foundation  of  the  so-called  "  double  pulse." 


Chap,  xv.]         THE   WRIST  AND  HAND.  261 

The  wrist  joint. — The  tip  of  the  styloid  process 
of  the  ulna  corresponds  to  the  line  of  the  wrist  joint, 
and  a  knife  entered  below  that  point  would  enter  the 
articulation.  A  knife  entered  horizontally  just  below 
the  tip  of  the  styloid  process  of  the  radius  would 
hit  the  scaphoid  bone.  A  line  drawn  between  the 
two  styloid  processes  would  slope  downwards  and 
outwards,  its  two  extremities  would  represent  the 
extreme  inferior  limits  of  the  radio-carpal  joint,  and 
would  fairly  correspond  to  the  chord  of  the  arc 
formed  by  the  line  of  that  joint.  The  line  between 
the  styloid  processes  would  be  nearly  half  an  inch 
below  the  summit  of  the  arch  of  the  wrist  joint. 

There  are  several  folds  in  the  skin  on  the  front  of 
the  wrist ;  of  these,  the  lowest  is  the  most  distinct. 
It  is  a  little  convex  downwards,  precisely  crosses  the 
neck  of  the  os  magnum  in  the  line  of  the  third  meta- 
carpal  bone  (Tillaux),  and  is  not  quite  three-quarters 
of  an  inch  below  the  arch  of  the  wrist  joint.  It  is 
about  half  an  inch  above  the  carpo-metacai-pal  joint 
line,  and  indicates  very  fairly  the  upper  border  of  the 
anterior  annular  ligament. 

The  palmar  surface  of  hand. — The  palm  is  con- 
cave in  the  centre  where  the  skin  is  adherent  to  the 
palmar  fascia.  This  "  hollow  of  the  hand  "  is  of  some- 
what triangular  outline,  with  the  apex  upwards.  On 
either  side  are  the  thenar  and  hypothenar  eminences. 
At  the  upper  end  of  the  former  eminence,  a  bony  pro- 
jection is  felt,  just  below  and  internal  to  the  radial 
styloid  process,  that  is  formed  by  the  tubercle  of  the 
scaphoid  and  ridge  on  the  trapezium.  The  interval 
separating  these  two  processes  of  bone  cannot  always 
be  made  out.  At  the  upper  extremity  of  the  hypothenar 
eminence  is  the  projection  of  the  pisiform  bone,  and 
just  below  it  the  unciform  process  can  be  identified. 
Below  the  hollow  of  the  palm,  and  opposite  the  clefts 
between  the  four  fingers,  three  little  elevations  are 


262 


SURGICAL  APPLIED  ANATOMY.    [Chap,  xv 


seen,  especially  when  the  first  phalanges  are  extended, 
and  the  second  and  third  are  flexed.     These  corre- 


Fig.  26.— Surface  Markings  on  the  Palm  of  the  Hand. 
The  thick  black  lines  represent  the  chief  creases  on  the  skin. 

spond  to  the  fatty  tissue  between  the  flexor  tendons 
and    the    digital    slips   of    the   palmar   fascia.     The 


Chap,  xv.]         THE   WRisr  AND  HAND.  263 

grooves  that  may  be  seen  to  separate  the  elevations 
correspond  to  those  slips. 

Of  the  many  creases  in  the  skin  of  the  palm 
three  require  especial  notice.  The  first  starts 
at  the  wrist,  between  the  thenar  and  hypothenar 
eminences,  and  marking  off  the  former  eminence 
from  the  palm  ends  at  the  outer  border  of  the 
hand  at  the  base  of  the  index  finger.  The  second 
fold  is  slightly  marked.  It  starts  from  the  outer 
border  of  the  hand,  where  the  first  fold  ends.  It  runs 
obliquely  inwards  across  the  palm  with  a  marked 
inclination  towards  the  wrist,  and  ends  at  the  outer 
limit  of  the  hypothenar  eminence.  The  third,  lowest, 
and  best-marked  of  the  folds  starts  from  the  little 
elevation  opposite  the  cleft  between  the  index  and 
middle  fingers,  and  runs  nearly  transversely  to  the 
ulnar  border  of  the  hand,  crossing  the  hypothenar 
eminence  at  the  upper  end  of  its  lower  fourth.  An 
unimportant  crease  running  obliquely  from  the  third 
to  the  second  fold  gives  to  these  markings  the  outline 
of  the  letter  M.  The  first  fold  is  produced  by  the 
opposition  of  the  thumb,  the  second  mainly  by  the 
bending  simultaneously  of  the  metacarpo-phalangeal 
joints  of  the  first  and  second  fingers,  and  the  third  by 
the  flexion  of  the  three  inner  fingers.  The  second 
fold,  as  it  crosses  the  third  metacarpal  bone,  about 
corresponds  to  the  lowest  point  of  the  superficial 
palmar  arch.  The  third  fold  crosses  the  necks  of  the 
metacarpal  bones,  and  indicates  pretty  nearly  the 
upper  limits  of  the  synovial  sheaths  for  the  flexor 
tendons  of  the  three  outer  fingers.  A  little  way 
below  this  fold  the  palmar  fascia  breaks  up  into  its 
four  slips,  and  midway  between  the  fold  and  the  webs 
of  the  fingers  lie  the  metacarpo-phalangeal  joints. 
Of  the  transverse  folds  across  the  fronts  of  the  fingers 
corresponding  to  the  metacarpo-phalangeal  and  phalan- 
geal  joints,  the  highest  is  single  for  the  index  and 


264  SURGICAL  APPLIED  ANATOMY.    [Chap. xv. 

little  finger,  and  double  for  the  other  two.  It  is 
placed  neaiiy  three-quarters  of  an  inch  below  the 
corresponding  joint.  The  middle  folds  are  double  for 
all  the  fingers,  and  are  exactly  opposite  the  first  inter- 
phalangeal  joints.  The  lowest  creases  are  single,  and 
are  placed  a  little  above  the  corresponding  joints  (I  to 
2  mm.,  according  to  Paulet).  There  are  two  single 
creases  011  the  thumb  corresponding  to  the  two  joints, 
the  higher  crossing  the  metacarpo-phalangeal  articula- 
tion obliquely.  The  free  edge  of  the  web  of  the  fingers, 
as  measured  from  the  palmar  surface,  is  about  three- 
quarters  of  an  inch  from  the  metacarpo-phalangeal 
joints.  The  superficial  palmar  arch  may  be  repre- 
sented by  a  curved  line  across  the  palm  starting  from 
the  pisiform  bone  and  running  in  a  line  with  the 
palmar  border  of  the  thumb  when  outstretched  at 
right  angles  with  the  index  finger.  The  deep  arch  is 
between  a  quarter  and  half  an  inch  nearer  the  wrist. 
The  digital  arteries  bifurcate  about  half  an  inch  above 
the  clefts  between  the  fingers. 

The  dorsal  surface  of  hand. — On  the  outer  side 
of  the  wrist,  when  the  thumb  is  extended,  a  hollow  is 
obvious  between  the  extensores  ossis  metacarpi  and 
forevis  pollicis  and  the  extensor  longus  pollicis. 
French  writers  have  termed  this  hollow  "tabatiere 
anatomique."  Across  this  hollow  and  beneath  the 
tendons  just  named  runs  the  radial  artery.  Under  the 
skin  over  the  space  can  usually  be  seen  a  large  vein, 
the  cephalic  vein  of  the  thumb/.  Across  the  space 
also  runs  the  internal  division  of  the  terminal  branch 
of  the  radial  nerve.  In  the  floor  of  the  "  snuff- 
box "  are  the  scaphoid  bone  and  the  trapezium.  The 
extensor  longus  pollicis  crosses  the  apex  of  the 
first  interosseous  space.  The  sesamoid  bones  of 
the  thumb  and  the  joint  between  the  trapezium 
and  the  first  metacarpal  bone  can  be  well  made  out. 
The  latter  articulation  is  situate  on  the  floor  of  the 


Chap.xv.i         THE  WRIST  AND  HAND.  265 

"tabatiere."  On  the  back  of  the  hand  the  various 
tendons  and  the  surface  veins  can  all  be  well  made 
out.  Between  the  first  and  second  metacarpal  bones 
is  the  first  dorsal  interosseous  muscle,  which  forms  a 
conspicuous  prominence  when  the  thumb  is  pressed 
against  the  side  of  the  index  finger.  The  three  rows 
of  knuckles  are  formed  by  the  proximal  bones  of  the 
several  joints. 

The  wrist  and  hand. —  The  skin  of  the  palm 
and  of  the  front  of  the  fingers  is  thick  and  dense, 
while  that  on  the  back  of  the  hand  is  much  finer. 
The  palm,  the  fronts,  and  sides  of  the  fingers,  and  the 
dorsal  aspects  of  the  last  phalanges,  all  show  an  entire 
absence  of  hair,  and  of  sebaceous  glands.  These  parts 
are,  therefore,  exempt  from  the  maladies  that  attack 
hair  follicles  and  their  gland  appendages.  On  the 
dorsum  of  the  hand,  and  of  the  first  and  second  rows 
of  phalanges,  there  are  numerous  hail's  and  sebaceous 
follicles.  Sweat  glands  are  more  numerous  in  the 
skin  of  the  palm  than  in  any  other  part.  According 
to  Sappey  they  are  four  times  more  numerous  here  than 
they  are  elsewhere.  Krause  has  estimated  that  nearly 
2,800  of  these  glands  open  upon  a  square  inch  of  the 
palm.  Only  about  half  the  number  are  found  upon 
the  dorsum  of  the  hand.  The  profuseness  with  which 
the  palm  may  perspire  is  well  known,  and  is  very 
marked  in  certain  conditions.  The  cutaneous  nerve- 
supply  of  the  hand  is  very  free.  The  nerves  present 
Pacinian  bodies,  which  are  far  more  numerous  in  the 
hand  than  in  any  other  part,  and  in  no  portion  of 
the  surface  are  tactile  corpuscles  more  numerous  or 
more  highly  developed.  With  the  exception  of  the 
tip  of  the  tongue,  a  more  acute  degree  of  tactile 
sensibility  is  met  with  in  the  hand  than  in  any 
other  part.  The  most  sensitive  district  is  the 
palmar  surface  of  the  third  phalanx  of  the 
index  finger,  while  the  least  sensitive  to  tactile 


266  SURGICAL   APPLIED  ANATOMY.    [Chap.  xv. 

impressions  is  the  dorsum  of  the  hand.  It  may  be 
said  that  the  tips  of  the  fingers  are  about  thirty  times 
more  acute  to  the  sense  of  touch  than  is  the  skin  of 
the  middle  of  the  fore-arm,  which  is  among  the  least 
sensitive  portions  of  the  integument  as  regards  tactile 
influences. 

The  subcutaneous  tissue  of  the  front  of  the  hand, 
and  especially  of  the  palm,  is  scanty  and  dense,  and 
somewhat  resembles  the  subcutaneous  tissue  of  the 
scalp  in  that  the  skin  is  closely  adherent  to  it,  and  the 
fat  it  contains  is  arranged  in  minute  lobules  lodged 
in  lacunae.  The  subcutaneous  tissue  on  the  dorsum 
is,  on  the  other  hand,  lax,  and  has  but  a  frail 
association  with  the  skin.  Thus  it  follows  that 
subcutaneous  extravasations  of  blood  are  practically 
impossible  in  the  palm,  and  on  the  anterior  aspect 
of  the  fingers,  while  they  may  be  very  extensive  on 
the  dorsum.  In  like  manner  oedema  of  the  extremity 
is  conspicuously  marked  upon  the  dorsal  surface,  while 
the  palm  remains  comparatively  free  even  in  severe 
cases.  Surface  inflammations  also  of  the  dorsum  are 
attended  with  considerable  swelling,  while  those  of 
the  front  of  the  hand  show  no  such  feature.  At  the 
same  time  the  adhesion  of  the  palmar  integument  to 
the  deeper  parts  is  so  close  that  surface  wounds  do  not 
gape,  and  are  in  a  position  to  encourage  ready  healing. 
The  denseness  of  the  integuments  of  the  palm  renders 
inflammation  of  the  part  extremely  painful,  owing 
to  the  tension  that  is  so  readily  produced,  whereas 
inflammation  in  the  lax  tissues  on  the  dorsum  may 
reach  some  magnitude  without  causing  great  pain. 
The  palm  of  the  hand  is  well  adapted  to  meet  the 
effects  of  pressure  and  friction.  The  cuticle  is  thick, 
the  skin  is  adherent,  and  immediately  beneath  it  lies 
the  dense  palmar  fascia.  This  fascia  efficiently 
protects  the  palmar  nerves  and  the  main  vessels,  while 
it  must  be  noted  that  the  front  of  the  hand,  and 


Chap,  xv.]          THE   WRIST  AND  HAND.  26  j 

especially  the  palm,  is  singularly  free  from  surface 
veins.  Indeed,  the  great  bulk  of  the  blood  from  the 
hand  is  returned  by  the  superficial  veins  on  the 
dorsum  of  the  fingers  and  hand. 

The  lymphatics  of  the  palm  are,  moreover,  scanty, 
and  very  minute,  whereas  on  the  dorsum  they  are 
large  and  profusely  distributed.  The  ulnar  border  of 
the  palmar  part  of  the  hand  is  much  used  in  pressure 
and  in  "hammering"  movements,  and  it  is  significant 
that  this  surface  is  well  protected  by  soft  parts,  and 
presents  a  singular  absence  of  large  nerves,  that,  if 
present,  would  be  liable  to  sustain  damage  from  such 
movements. 

The  form  of  the  nail  varies  somewhat  in  individuals, 
and,  according  to  certain  authors,  there  are  special 
types  of  nail  to  be  met  with  in  some  constitutional 
diseases.  Thus  are  described  the  tubercular,  the 
rachitic,  the  arthritic  nail.  By  the  Hippocratic  hand 
is  meant  a  hand  the  tips  of  the  fingers  of  which  are 
clubbed,  and  the  nails  of  which  are  much  curved. 
This  condition  would  appear  to  be  due  to  impeded 
circulation,  to  retardation  in  the  return  of  venous 
blood,  and  perhaps  also  to  imperfect  oxygenation  of 
that  blood.  It  is  most  often  met  with  in  congenital 
heart  disease,  in  phthisis,  empyema,  chronic  lung 
affections,  certain  thoracic  aneurisms,  and  some  forms 
of  scrofula.*  There  are  several  forms  of  inflammation 
affecting  the  matrix  of  the  nail  and  the  soft  parts 
immediately  around  it  (onychia,  paronychia).  Such 
inflammations  lead  to  great  deformity  of  the  structure 
itself.  When  a  nail  is  thrown  off  by  suppuration  or 
violence  a  new  nail  is  produced,  provided  any  of  the 
deeper  epithelial  cells  are  left.  During  convalescence 
from  certain  illnesses  (e.g.,  scarlet  fever),  a  transverse 
groove  will  appear  across  all  the  nails.  This  groove 

*  See  "  Scrofula  and  its  Gland  Diseases,"  p.  99.  By  the 
Author.  London.  1882. 


?68  SURGICAL  APPLIED  ANATOMY.    [Chap  xv. 

indicates  the  portion  of  nail  formed  during  the  illness, 
and  by  watching  its  movement  the  rate  of  growth  of  the 
nail  can  be  estimated.  The  nail  grows  at  the  average 
rate  of  -^nd  of  an  inch  per  week.  It  may  be  noted  that 
each  digital  nerve  gives  a  special  branch  of  large  size  to 
the  pulp  beneath  the  nail,  and  this  explains  the  intense 
pain  felt  when  a  foreign  body  is  thrust  under  the  nail. 

The  fasciae. — Beneath  the  skin  of  the  palm  is  the 
dense  palmar  fascia.  This  fascia  gives  almost  as  much 
strength  to  the  hand  as  would  so  much  bone,  while  its 
unyielding  character,  its  comparative  freedom  from 
vessels  and  nerves,  render  it  well  suited  to  withstand 
the  effects  of  pressure.  The  fascia  gives  slips  to  each 
finger  ;  each  slip  sends  fibres  to  join  the  digital  sheaths 
of  the  tendons,  the  skin,  and  the  superficial  transverse 
ligament.  In  the  disease  known  as  Dupuytren's  con- 
traction, the  palmar  fascia,  and  especially  its  digital 
slips,  becomes  contracted.  One  or  more  or  all  of  the 
fingers  may  be  involved  in  the  contraction.  The  first 
phalanx  is  drawn  or  flexed  towards  the  palm,  and  later 
the  second  phalanx  becomes  bent  also.  The  skin  is 
drawn  in  towards  the  fascia,  since  the  two  structures 
are  normally  connected  with  one  another.  Experi- 
ment shows  that  by  dragging  upon  the  fascia  the  first 
phalanx  can  be  readily  bent,  and  also,  but  with  less 
ease,  the  second  phalanx. 

The  structures  of  the  palm  are  divided  into  three 
spaces  by  the  fasciae  (Fig.  27).  Thus  the  muscles  of  the 
thenar  and  hypothenar  eminences  are  both  enclosed  in 
a  thin  fascia  proper  to  each.  The  two  spaces  formed  by 
these  membranes  are  enclosed  in  all  directions,  and  are 
capable,  though  only  in  a  feeble  way,  of  limiting  sup- 
puration when  it  commences  in  them.  Between  these 
two  spaces  is  a  third  space,  which  is  roofed  in  by  the 
palmar  fascia.  This  cavity  is  closed  in  at  the  sides, 
but  is  open  above  and  below.  Above  there  is  a 
free  opening  beneath  the  annular  ligament  and  along 


Chap,  xv.]        THE  WRIST  AND  HAND.  269 

the  flexor  tendons  into  the  fore-arm,  while  below 
there  are  the  seven  passages  provided  for  by  the 
division  of  the  palmar  fascia.  Of  these  seven 
passages,  four,  situate  at  the  roots  of  the  several 
fingers,  give  passage  to  the  flexor  tendons,  while  the 
remaining  three  correspond  to  the  webs  between  the 


i 


Fig.  27.— Horizontal  Section  of  the  Hand  through  the  middle  of  the 
Thenar  and  Hypothenar  Eminences  (Tillaiix). 

a,  Mctacarpal  bone  ;  6,  first  dorsal  interosseous  ;  c,  iialmaris  brevis  ;  <?,abductor 
min. digit! ;  e,  flexor  brevis  miu.  dig. ;  /,  opponens  inin.  dig--  ;  0,  flexor  brevis 
poll.;  fc,  abductor  poll.;  i,  opponeus  poll.;  y,  adductor  poll.;  fc,  flexor  long. 
IM>!.  ;  I,  dorsal  interossei ;  m,  palmar  interossei ;  n,  flexor  subliiuis;  o,  flexor 
prof  undue ;  p,  superflc.  volae ;  a,  median  nerve,  and  (on  inner  side)  ulnar  artery 
and  nerve:  r,  deep  palmar  arch  ;  1,  palmar  fascia;  2,  outer  septum;  3,  iuuer 
septum ;  4,  deep  fascia  of  palm. 

fingers,  and  give  passage  to  the  lumbricales  and  the 
digital  vessels  and  nerves.  When  pus,  therefore, 
forms  in  the  palm,  beneath  the  palmar  fascia,  it 
cannot  come  forward  through  that  dense  membrane, 
but  escapes  rather  along  the  fingers,  or  makes  its  way 
up  into  the  fore-arm.  So  rigid  is  the  resistance  offered 
by  the  palmar  fascia,  that  pent-up  pus  will  make  its 
way  through  the  interosseous  spaces  and  appear  on  the 
dorsum  of  the  hand,  rather  than  come  through  the 
coverings  of  the  palm.  The  passage  of  pus,  however, 
towards  the  dorsum  is  resisted  by  a  layer  of  fascia 


270  SURGICAL   APPLIED  ANATOMY.     [.Chap,  xv. 

that  lies  deeply  beneath  the  flexor  tendons,  and  covers 
in  the  interossei  muscles,  the  bones,  and  the  deep 
palmar  arch.  This  fascia  joins  on  either  side  the 
fasciae  enclosing  the  thenar  and  hypothenar  "  spaces  " 
(Fig.  27). 

In  opening  a  palmar  abscess,  when  it  points  above 
the  wrist,  the  incision  should  be  in  the  long  axis 
of  the  fore-arm,  should  be  above  the  annular  ligament, 
and  is  most  conveniently  made  a  little  to  the  ulnar 
side  of  the  palmaris  longus,  for  a  cut  in  this  position 
would  escape  both  the  ulnar  and  radial  arteries  and 
also  the  median  nerve. 

The  tendons  about  the  wrist  are  bound  down  and 
held  in  place  by  the  annular  ligaments.  So  dense 
is  the  anterior  ligament,  that  even  in  extensive  abscess 
of  the  palm  reaching  into  the  fore-arm,  and  in  severe 
distension  of  the  synovia!  sheaths  beneath  the  liga- 
ment, it  remains  firm,  and  will  not  yield.  The 
lower  border  of  the  posterior  annular  ligament 
corresponds  to  the  upper  edge  of  the  anterior  band, 
and  these  structures  together  act  the  part  of  the 
leather  bracelet  that  the  labourer  sometimes  wears 
around  his  wrist,  and  that,  in  fact,  takes  the  function 
of  an  additional  annular  ligament. 

The  fibrous  sheaths  for  the  flexor  tendons  ex- 
tend from  the  metacarpo-phalangeal  joints  to  the  upper 
ends  of  the  third  phalanges.  The  pulp  of  the  third 
phalanx,  therefore,  rests  practically  upon  the  perios- 
teum. Opposite  the  finger  joints  the  sheaths  are  lax 
and  thin,  and  spaces  may  occur  between  the  decussat- 
ing fibres  of  the  sheaths,  through  which  the  synovial 
membrane  lining  the  sheath  may  protrude.  It  is,  I 
believe,  through  this  less  protected  part  of  the  sheath 
that  suppuration  without  often  finds  its  way  into  the 
interior  of  the  sheath.  The  sheaths  in  the  rest  of 
their  course  are  dense  and  rigid,  and  when  cut  across 
remain,  in  virtue  of  this  rigidity,  wide  open  (Fig. 


Chap,  xv.]        THE   WRIST  AND  HAND.  271 

28).  Thus,  after  the  division  of  the  sheath,  as  in 
amputation,  an  open  channel  is  left  leading  into  the 
palni  of  the  hand,  and  offering  the  greatest  facility  for 
the  spread  of  pus  into  that  part.  It 
is  this  rigidly  open  fibrous  sheath  that 
probably  may  explain,  the  frequency  of 
suppuration  in  the  palm  after  amputa- 
tion of  a  part  of  a  finger,  and  I  am 
decidedly  of  opinion  that  some  steps 
should  be  taken  to  protect  or  shut  off 
this  channel  in  any  case  where  the 
sheath  has  been  accidentally  or  inten-  ^nta^'section 
tionally  divided.  through  middle 

Synovial  sacs  and  sheaths* —       Lnx^Taiaux)8" 
There   are  two  synovial  sacs  beneath     „.  Flexor  tendon; 

•  i  IT  £          ±1          n  6,  flbrous  sheath 

the  annular    ligament    tor   the   flexor        oi  tendon :  c,  ei- 

i  £  .  i  n  i  tensor     tendnn ; 

tendons,  one  for  the  flexor  Jongus  <*,  di^tai  artery 
pollicis,  the  other  for  the  flexor  sub- 
limis  and  profundus  tendons.  The 
former  extends  up  into  the  fore-arm  for  about  l£ 
inches  above  the  annular  ligament,  and  follows  its 
tendon  to  its  insertion  in  the  last  phalanx  of  the 
thumb.  The  latter  rises  about  1^  inches  above  the 
annular  band,  and  ends  in  diverticula  for  the  four 
fingers.  The  process  for  the  little  finger  usually 
extends  to  the  insertion  of  the  flexor  profundus  tendon 
in  the  last  phalanx.  The  remaining  three  diverticula 
end  about  the  middle  of  the  corresponding  metacarpal 
bones.  The  synovial  sheaths  for  the  digital  part  of  the 
tendjons  to  the  index,  middle,  and  ring-fingers,  end 
above  about  the  neck  of  the  metacarpal  bones,  and  are 
thus  separated  by  about  a  quarter  to  half  an  inch  from 
the  great  synovial  sac  beneath  the  annular  ligament. 
Thus  there  is  an  open  channel  from  the  ends  of  the 
thumb  and  little  finger  to  a  point  in  the  fore-arm, 
some  inch  and  a  half  above  the  annular  ligament. 
The  arrangement  explains  the  well-known  surgij;il 


273  SUXGICAL    APPLIED  ANATOMY.     [Chap,  xv 

fact  that  abscesses  of  the  thumb  and  little  finger  are 
apt  to  be  followed  by  abscesses  in  the  fore-arm,  while 
such  a  complication  is  not  usual  after  suppuration  in 
the  remain-ing  fingers.  The  synovial  sac  for  the 
flexor  tendons  is  narrowed  as  it  passes  beneath  the 
annular  ligament,  and  thus  it  happens  that  when 
distended  with  fluid  or  with  pus,  it  presents  an 
hour-glass  outline,  the  waist  of  the  hour-glass  corre- 
sponding to  the  ligament.  The  two  synovial  sacs  be- 
neath the  ligament  sometimes  communicate  with  one 
another. 

In  one  form  of  whitlow,  that  form  where  the  pus 
occupies  the  synovial  sheaths  of  the  tendons  on  the 
fingers  (thecal  abscess),  the  suppuration  can  often  be 
seen  to  end  abruptly  where  the  sheath  endn,  when  the 
index,  middle,  or  ring-finger  is  involved,  viz.,  opposite 
the  neck  of  the  corresponding  metacarpal  bones.  In 
another  form  of  whitlow  (the  abscess  in  the  pulp  at 
the  end  of  the  finger)  the  periosteum  of  the  third 
phalanx  is  readily  attacked,  there  being  no  inter- 
vening tendon  sheath  over  that  bone.  In  this 
affection  the  bone  often  necroses  and  comes  away, 
but  it  is  significant  to  note  that  it  is  very  seldom  that 
the  whole  of  the  phalanx  perishes.  The  upper  part, 
or  base,  of  the  bone  usually  remains  sound,  and  is 
probably  preserved  by  the  insertion  of  the  flexor 
profundus  tendon.  It  is  also  interesting  to  bear  in 
mind  that  the  base  of  the  bone  is  an  epiphysis  that 
does  not  unite  to  the  shaft  until  the  eighteenth  or 
twentieth  year. 

Beneath  the  posterior  annular  ligament  there  are 
six  synovial  sheaths  for  tendons,  corresponding  to  the 
six  canals  formed  by  that  ligament.  The  sheath 
most  frequently  inflamed  is  that  for  the  extensores 
ossi  metacarpi  and  brevis  pollicis.  It  runs  from  a 
point  about  three-quarters  of  an  inch  above  the 
radial  styloid  process  to  the  first  carpo-metacarpal 


Chap,  xv.]         THE   WRIST  AND  HAND.  273 

joint.  The  other  sheaths  reach  above  to  the  upper 
border  of  the  annular  ligament,  that  for  the  two 
radial  extensors,  however,  beginning  about  half  an 
inch  above  the  ligament.  The  sheaths  for  the  extensor 
communis  and  the  extensor  minimi  digiti  extend  below 
to  the  middle  of  the  metacarpus.  That  for  the 
extensor  indicis  barely  reaches  the  metacarpus.  The 
other  sheaths  follow  the  tendons  to  their  insertions. 

Blood-vessels  and  lymphatics. — The  hand 
is  very  well  supplied  with  blood,  and  indeed  the  finger 
pulp  is  one  of  the  most  vascular  parts  in  the  body. 
Cases  are  recorded  where  the  tip  of  the  finger  has  been 
accidentally  cut  off,  and  has  grown  again  to  the  limb 
on  being  immediately  re-applied.  The  position  of  the 
palmar  arches  has  been  pointed  out.  Wounds  of  these 
arches,  and  indeed  of  most  of  the  arteries  of  the  palm 
and  wrist,  are  serious,  on  account  of  the  difficulty  of 
reaching  the  bleeding  point  without  seriously  damaging 
important  structures,  and  on  account  of  the  free  anas- 
tomoses that  exist  between  the  vessels  of  the  part. 
The  deep  palmar  arch  may  be  wounded  by  a  pene- 
trating wound  from  the  dorsum,  and  indeed  Delorme 
has  .pointed  out  that  this  arch  may  be  ligatured 
from  the  dorsum  after  a  preliminary  resection  of 
the  upper  part  of  the  third  metacarpal  bone.  It  is 
well  known  that  hemorrhage  from  either  of  the 
palmar  arches  cannot  be  checked  by  ligature  of  the 
radial  or  ulnar  artery  alone,  on  account  of  the  connec- 
tion of  the  arches  with  those  vessels ;  and  it  is  also 
known  that  simultaneous  ligation  of  the  two  vessels 
may  have  no  better  effect,  owing  to  the  anastomoses 
between  the  palmar  arches  and  the  interosseous 
vessels.  The  anastomosis  is  carried  on  by  means  of 
the  carpal  arches.  The  anterior  carpal  arch  communi- 
cates with  the  anterior  interosseous  artery  above,  and 
with  the  deep  palmar  arch, .  by  the  recurrent  vessels 
below.  The  posterior  carpal  arch  communicates  with 


274  SURGICAL    APPLIED   ANATOMY.    [Chap.  xv. 

the  two  interosseous  vessels  above,  and  with  the  deep 
palmar  arch  below,  by  means  of  the  perforating 
branches  from  the  latter  vessel.  The  anastomosis 
between  the  two  palmar  arches  is  well  known,  and  is 
freely  established  both  by  the  main  vessels  themselves 
and  by  the  communion  that  exists  between  the  digital 
arteries  from  the  superficial  arch  and  the  palmar  inter- 
osseous  branches  from  the  deeper  vessel.  In  bleeding 
from  the  palm,  the  simultaneous  ligature  of  the 
radial  and  ulnar  arteries  may  also  entirely  fail  in 
those  cases  where  the  arches  are  freely  joined,  or  are 
more  or  less  replaced  by  large  and  abnormal  inter- 
osseous  vessels,  or  by  a  large  "  median "  artery. 
When  either  the  radial  or  the  ulnar  part  of  the  arches 
is  defective,  the  lack  is  usually  supplied  by  the  other 
vessel ;  and  it  is  well  to  note  that  the  deficiency  is 
most  common  in  the  superficial  or  ulnar  arch. 
Pressure  applied  to  the  palm  to  arrest  bleeding  is  apt 
to  cause  gangrene,  owing  to  the  rigidity  of  the  parts 
and  the  ease  with  which  considerable  pressure  can 
be  applied. 

The  radial  artery,  as  it  curves  round  the  back  of 
the  hand  to  reach  the  deeper  part  of  the  palm,  is  in 
close  contact  with  the  carpo-metacarpal  joint  of  the 
thumb.  This  fact  must  be  borne  in  mind  in  amputa- 
tion of  the  entire  thumb,  and  also  in  resection  of  the 
first  metacarpal  bone.  The  superficialis  vola?,  if  large, 
may  bleed  seriously.  It  adheres  to  the  surface  of 
the  annular  ligament,  and  may  therefore  be  difficult 
to  pick  up  when  wounded. 

From  the  larger  size  and  great  mimber  of  the 
lymphatics  about  the  fingers  and  on  the  dorsum  of  the 
hand,  it  follows  that  lymphangitis  is  more  common 
after  wounds  of  those  parts  than  it  is  after  wounds 
of  the  palm. 

The  bones  and  joints. — The  inferior  radio- 
nlnar  joint  is  supported  by  the  powerful  triangular 


XV.T         THE   WRIST  AND  HAND.  275 

fibro-cartilage,  which  forms  the  strongest  and  most 
important  of  all  the  ligamentous  connections  between 
the  two  bones.  The  synovial  sheath  of  the  extensor 
minimi  digiti  sometimes  communicates  with  this  joint, 
and  may  therefore  be  involved  when  that  articulation 
is  diseased. 

The  strength  of  the  wrist  joint  depends  not  so 
much  upon  its  mechanical  outline  or  its  ligaments  as 
upon  the  numerous  strong  tendons  that  surround  it, 
and  that  are  so  closely  bound  down  to  the  bones  about 
the  articulation.  Its  strength  depends  also  upon  its 
proximity  to  the  numerous  bones  and  joints  of  the  hand, 
whereby  all  movements  and  shocks  are  distributed 
between  several  articulations.  Moreover,  in  the  case 
of  the  wrist  the  long  lever  does  not  exist  on  the  distal 
side  of  the  joint.  The  movements  of  the  wrist  are 
greatly  supplemented  by  those  of  the  mid-carpal  joint. 
The  anterior  ligament  of  the  wrist  is  the  strongest 
ligament  of  the  joint,  while  the  posterior  is  the 
weakest.  The  former  structure  limits  extension,  and 
the  latter  flexion  ^nd  in  connection  with  this  arrange- 
ment it  is  interesting  to  note  that  injury  fi*om  forced 
extension  is' more  common  than  from  forced,  flexion. 
Thus;  when  a  man  falls  upon  the  hand,  he  more 
usually  falls  upon  the  palm  (forced  extension)  than 
upon  the  dorsum  (forced  flexion).  Owing  to  the 
thinness  of  the  posterior  ligament,  together  with  the 
more  superficial  position  of  the  hinder  part  of  the 
joint,  it  follows  that  the  effusion  in  wrist-joint  disease 
is  first  noticed  at  the  back  of  the  hand.  As  the 
tendons  on  the  front  and  at  the  back  of  the  wrist 
fairly  balance  one  another,  the  hand  in  wrist-joint 
disease  shows  little  tendency  to  be  displaced,  but  is 
fixed  rather  in  the  mid-position  between  flexion  and 
extension.  It  can  be  understood  that  in  this  disease 
the  neighbouring  synovial  sheaths  are  readily  involved. 

Tn  connection  with  this  joint   it  may  be   noted 


276  SURGICAL   APPLIED  ANATOMY,    [chap.  xv. 

that  the  middle  finger  is,  from  its  greater  length, 
the  one  most  exposed  to  injury  and  to  shocks  received 
by  the  fingers.  Its  metacarpal  bone  is  directly 
received  by  the  strongest  carpal  bone,  the  os  magnum, 
and  the  latter  bone  is  brought  by  means  of  the 
semi-lunar  in  connection  with  the  widest  and  strongest 
part  of  the  radius. 

But  little  movement  is  allowed  in  the  metacarpc- 
carpal  joints  of  the  first  three  fingers,  but  in  the  like 
joints  of  the  thumb  and  little  finger  movements  are 
free,  and  their  preservation  is  of  great  importance  to 
the  general  usefulness  of  the  hand.  The  glenoid  liga- 
ments in  front  of  the  three  finger-joints  are  firmly 
attached  to  the  distal  bone,  and  but  loosely  to  the 
proximal.  Thus  it  happens  that  in  dislocation  of  the 
distal  bone  backwards,  the  glenoid  ligament  is  carried 
with  it,  and  offers  a  great  obstacle  to  reduction.  In 
flexing  the  second  and  third  finger  joints  alone,  it  will 
be  seen  that  the  first  phalanx  is  steadied  by  the  ex- 
tensor tendon  as  a  preliminary  measure,  and  in 
paralysis  of  the  extensors  flexion  of  these  two  joints 
alone  is  not  possible. 

Very  few  persons  have  the  power  of  flexing  the 
last  finger  joint  without  at  the  same  time  bending  the 
articulation  above  it ;  but  in  certain  inflammatory 
affections  about  the  last  phalanges  the  terminal  joint 
is  sometimes  seen  to  be  fixed  in  a  flexed  posture  while 
the  other  finger  joints  are  straight.  I  imagine  that 
this  position  must  always  indicate  some  disease  of  the 
articulation  itself. 

Colics'  fracture. — This  name  is  given  to  a 
transverse  fracture  through  the  lower  end  of  the 
radius,  from  a  half  to  one  inch  above  the  wrist  joint. 
It  is  associated  with  a  certain  definite  deformity,  and 
is  always  the  result  of  indirect  violence,  a  fall  upon 
the  outstretched  hand.  There  are  good  reasons  why 
the  bone  should  break  in  this  situation.  The  lower 


Chap,  xv.]          THE  WRIST  AND  HAND.  277 

end  of  the  radius  is  very  cancellons,  while  the  shaft 
contains  a  good  deal  of  compact  bone.  At  about 
three-quarters  of  an  inch  from  the  articular  sm-face, 
these  two  parts  of  the  bone  meet,  and  their  very 
unequal  density  greatly  tends  to  localise  the  fracture 
in  this  situation.  As  to  the  mechanism  of  this  lesion, 
many  different  opinions  are  still  held,  and  a  vast 
deal  has  been  written  on  the  subject.  I  subjoin  Pro- 
fessor Chiene's  account  of  this  lesion,  because  it  may 
be  taken  as  representing  with  admirable  clearness  the 
views  most  generally  accepted  at  the  present  time  as 
to  the  nature  of  this  injury.  Into  the  discussion  itself 
I  do  not  propose  to  enter.  The  deformity  in  Colics' 
fracture  is  entirely  due  to  the  displacement  of  the 
lower  fragment.  "  The  displacement  is  a  triple  one  :  (a) 
backwards,  as  regards  the  antero-posterior  diameter  of 
the  fore-arm ;  (6)  rotation  backwards  of  the  carpal  sur- 
face on  the  transverse  diameter  of  the  fore-arm;  (c)  rota- 
tion through  the  arc  of  a  circle,  the  centre  of  which  is 
situated  at  the  ulnar  attachment  of  the  triangular 
ligament,  the  radius  of  the  circle  being  a  line  from  the 
ulnar  attachment  of  the  triangular  ligament  to  the  tip 
of  th'e  styloid  process  of  the  radius,  (a)  When  a 
person  in  falling  puts  out  his  hand  to  save  himself,  at 
the  moment  the  hand  reaches  the  ground  the  force  is 
received  principally  by  the  ball  of  the  thumb,  and 
passes  into  the  carpus,  and  thence  into  the  lower  end 
of  the  radius.  If,  at  the  moment  of  impact,  the  angle 
between  the  axis  of  the  fore-arm  and  ground  is  less 
than  60°,  the  line  representing  the  direction  of  the 
force  passes  upwards  in  front  of  the  axis  of  the  fore- 
arm ;  the  whole  shock  is  therefore  borne  by  the  lower 
end  of  the-  radius,  which  is  broken  off,  and,  the  force 
being  continued,  the  lower  fragment  is  driven  back- 
wards. When  at  the  moment  of  impact  the  angle 
is  greater  than  60°,  the  line  of  the  force,  instead 
of  passing  in  front  of  the  axis  of  the  arm,  passes  up 


278  SURGICAL   APPLIED  ANATOMY.     [Chap. xv. 

the  arm,  and  the  usual  result  is  either  a  severe  sprain 
of  the  wrist,  or  a  dislocation  of  the  bones  of  the  fore- 
arm backwards  at  the  elbow  joint,  (b)  The  carpal 
surface  of  the  radius  slopes  forwards,  and  therefore 
the  posterior  edge  of  the  bone  receives  the  greater 
part  of  the  shock ;  there  is,  as  a  result,  rotation  of  the 
lower  fragment  backwards  on  the  transverse  'diameter 
of  the  fore-arm,  (c)  The  carpal  surface  of  the  radius 
slopes  downwards  and  outwards  to  the  radial  edge  of 
the  arm ;  therefore  the  radial  edge  of  the  bone  receives 
the  principal  part  of  the  shock  through  the  ball  of  the 
thumb.  As  a  result,  this  edge  of  the  lower  fragment 
is  displaced  upwards  to  a  greater  extent  than  the 
ulnar  edge  of  the  fragment,  which  remains  firmly 
attached  to  the  ulna  by  the  triangular  ligament." 
This  rotation  also  depends  upon  the  integrity  of  the 
inferior  radio-ulnar  ligament  in  a  typical  Colles'  frac- 
ture. These  ligaments  hold  on  to  the  ulnar  part  of 
the  lower  fragment,  and  prevent  its  being  displaced 
to  so  great  an  extent  as  is  the  radial  part  of  the  frag- 
ment. By  means  of  this  rotatory  displacement,  tire 
tips  of  the  two  styloid  processes  come  to  occupy  the 
same  level,  or  the  radial  process  may  even  mount  above 
the  ulnar.  In  nearly  every  case  there  is  some  pene- 
tration of  the  fragments,  the  compact  tissue  on  the 
dorsal  aspect  of  the  upper  fragment  being:  driven  (by 
a  continuance  of  the  force  that  broke  the  bone),  into 
the  cancellous  tissue  on  the  palmar  aspect  of  the  lower 
fragment.  It  is  only  in  very  rare  instances  that  the 
fragments  are  so  separated  as  to  ride  the  one  over  the 
other.  In  such  cases  the  radio-ulnar  ligaments  are 
probably  ruptured,  and  the  wrist  ceases  to  present  the 
typical  deformity  of  a  Colles'  fracture.  That  the 
deformity  in  Colles'  fracture  is  due  to  the  nature  and 
direction  of  the  force  is  indirectly  proved  by  an 
isolated  case  or  so,  where  the  patient  fell  upon  the 
back  of  the  hand,  with  the  result  that  the  radius  was 


Chap,  xv.]         Tn P.   WRIST  AND  HAND.  279 

broken  in  the  usual  position  of  a  Colles'  fracture,  but 
the  lower  fragment  was  carried  forwards  instead  of 
backwards.  According  to  R.  W.  Smith  and  others, 
the  peculiar  deformity  is  produced  by  muscular  action, 
principally  by  the  supinator  longus,  the  extensors  of 
the  thumb,  and  the  radial  extensors.  Lecomte  and 
many  French  writers  assert  that  the  fracture  is  due 
to  a  tearing  (arrachement)  of  the  bone  by  strain  upon 
the  ligaments  of  the  wrist.  Thus  they  assert  that  in 
forcible  extension  of  the  hand  the  carpal  condyle  is 
thrust  against  the  anterior  wrist  ligaments ;  these  are 
intensely  stretched,  and  tear  off  the  lower  end  of  the 
radius,  fracturing  it  through  what  is  acknowledged  to 
be  the  weakest  part  of  the  bone.  It  is  true  that  in 
young  subjects  the  lower  epiphysis  of  the  radius  can 
be  separated  in  the  cadaver  by  very  forcible  flexion  or 
extension  of  the  wrist  (B.  Anger).  This  epiphysis  is 
often  separated  by  accidental  violence.  It  joins  the 
shaft  about  the  twentieth  year.  Its  junction  with 
the  shaft  is  represented  by  a  nearly  horizontal  line, 
and  the  epiphysis  includes  the  facet  for  the  ulna 
and  the  insertion  of  the  supinator  longus.  Fractures 
of  the  lower  end  of  the  radius,  due  to  direct 
violence,  are  usually  associated  with  but  trifling  dis- 
placement. 

There  is  no  special  anatomical  interest  attach- 
ing to  fractures  of  the  carpus,  metacarpus,  or  pha- 
langes. 

Dislocations. — (1)  At  tlw  wrist  joint.  —  So 
strong  is  this  articulation,  for  the  reasons  above 
givCTi  (page  273),  that  carpo  -  radial  luxations  are  ex- 
tremqly  rare.  For  the  same  reasons,  when  they  do  occur 
they  are  ^usually  complicated,  and  are  associated 
with  tearing  of  the  skin,  or  rupture  of  tendons, 
or  fractures  of  the  adjacent  bones.  The  luxations 
of  the  carpufe  may  be  either  backwards  or  for- 
wards, the  latter  being  extremely  rara  They 


280  SURGICAL  APPLIED  ANA  TOMY.     [Chap.  xv. 

would  appear  to  be  produced  with  equal  ease  by 
a  fall  upon  either  the  front  or  the  back  of  the 
hand.  Bransby  Cooper  gives  the  case  of  a  lad  who 
fell  upon  the  outstretched  palms  of  both  his  hands : 
both  wrists  were  dislocated,  one  backwards,  the  other 
forwards. 

(2)  Some  dislocations  about  tJie  liand  (os  magnum). 
— In  forcible  flexion  of  the  hand,  the  os  magnum 
naturally  glides  backwards,  and  projects  upon  the 
dorsum.  In  very  extreme  flexion  (as  in  falls  upon,  the 
knuckles  and  dorsum  of  the  metacarpus),  this  move- 
ment of  the  bone  backwards  may  be  such  as  to  lead 
to  its  partial  dislocation,  the  luxation  being  associated 
with  some  rupture  of  ligaments.  In  one  recorded 
case,  this  luxation  was  produced  by  muscular  force. 
The  patient,  a  lady,  while  in  labour,  "  seized  violently 
the  edge  of  her  mattress,  and  squeezed  it  forcibly." 
Something  was  felt  to  give  way  in  the  hand,  and  the 
head  of  the  os  magnum  was  found  to  be  dislocated 
backwards. 

Dislocation  at  the  metacarpo-pJialangeal  joint  oj 
the  thumb. — In  this  luxation,  the  phalanx  is  usually 
displaced  backwards,  and  the  lesion  is  of  interest  on 
account  of  the  great  difficulty  often  experienced  in 
reducing  the  bone.  Many  anatomical  reasons  have 
been  given  to  explain  this  difficulty,  which  are  well 
summarised  by  Hamilton  in  the  following  passage ; 
"  Hey  believes  the  resistance  to  be  in  the  lateral  liga- 
ments, between  which  the  lower  end  of  the  metacarpai 
bone  escapes  and  becomes  imprisoned.  Ballingall, 
Malgaigne,  Erichsen,  and  Vidal  think  the  metacarpai 
bone  is  locked  between  the  two  heads  of  the  flexor 
brevis,  or,  rather,  between  the  opposing  sets  of  muscles 
which  centre  in  the  sesamoid  bones,  as  a  button  is 
fastened  into  a  button-hole.  Pailloux  and  others 
affirm  that  the  anterior  ligament,  being  torn  from  one 
of  its  attachments,  falls  between  the  joint  surfaces, 


Chap,  xv.j          THE   WRIST  AND  HAND.  281 

and  interposes  an  effectual  obstacle  to  reduction. 
Dupuytren  ascribes  the  difficulty  to  the  altered  rela- 
tions of  the  lateral  ligaments,  ...  to  the  spasm 
of  the  muscles,  and  to  the  shortness  of  the  member,  in 
consequence  of  which  the  force  of  extension  has  to  be 
applied  very  near  to  the  seat  of  the  dislocation. 
Lisfranc  found  in  an  ancient  luxation  the  tendon  of 
the  long  flexor  so  displaced  inwards,  and  entangled 
behind  the  extremity  of  the  bone,  as  to  prevent 
reduction."  The  explanation  most  usually  accepted 
is  that  that  ascribes  the  irreducibility  to  the 
"button -hole  action"  of  the  sesamoid  bones  and 
their  tendons. 

Avulsion  of  one  or  more  fingers  may  be  effected 
by  severe  violence.  In  such  cases  the  finger  torn  off 
usually  takes  with  it  some  or  all  of  its  tendons.  These 
tendons  are  practically  drawn  out  of  the  fore-arm, 
and  may  be  of  considerable  length.  Biltroth  figures  a 
case  where  the  middle  finger  was  torn  out,  taking 
with  it  the  two  flexor  and  extensor  tendons  in 
their  entire  length.  When  one  tendon  only  is  torn 
away  with  the  finger,  it  is  usually  that  of  the  flexor 
profundus. 

Amputation  at  the  wrist  joint  by  the  cir- 
cular method.  (See  the  author's  "Operative  Surgery.") 
In  the  dorsal  wound  would  be  cut  the  following  ten- 
dons :  the  extensores  longus,  inclicis,  communis,  minimi 
digiti,  and  ulnaris,  the  radial  nerve,  and  the  dorsal 
branch  of  the  ulnar  nerve.  The  two  radial  extensors 
will  be  cut  short  in  the  radial  angle  of  the  wound,  as 
will  also  be  the  extensores  ossis  and  brevis.  The  radial 
artery  will  be  divided  close  to  the  radius.  In  the  palmar 
wound  would  be  found  the  ulnar  artery,  the  superficialis 
volse,  the  ulnar  and  median  nerves,  the  opponens,  flexor 
brevis,  and  abductor  pollicis  in  part,  the  flexor  brevis, 
opponens,  and  abuctor  minimi  digiti  in  part  (the 
bulk  of  the  opponens  being  left  behind  on  the  hand), 


282  SURGICAL  APPLIED  ANATOMY.    [Chap.  xv. 

and  the  tendons  of  the  flexor  sublimis  and  flexor  carpi 
radialis.  The  tendons  of  the  flexor  profundus  and 
flexor  longus  pollicis  are  usually  cut  short  close  to  the 
bones. 

Amputation  of  the  thumb  at  the  carpo-meta- 
carpal  joint  by  flaps.  In  the  palmar  flap  would  be 
cut  the  abductor,  the  short  and  long  flexor,  the  op- 
ponens,  and  adductor  pollicis.  The  extensores  ossis 
and  brevis  would  be  cut  short  in  the  posterior  angle 
of  the  flap.  The  extensor  longus  and  a  considerable 
portion  of  the  abductor  indicis  would  be  found  in  the 
dorsal  flap.  The  vessels  divided  would  be  the  two 
dorsal  arteries  of  the  thumb  and  the  princeps  pollicis. 
There  is  great  danger,  in  this  operation,  of  wounding 
the  radialis  iadicis  and  the  radial  artery  itself  where  it 
begins  to  dip  into  the  palm. 

Nerve  supply  of  the  upper  limb. — In  the 
diagnosis  of  nerve  injuries  of  the  upper  limb  it  is  im- 
portant to  know  from  which  spinal  nerves  the  various 
muscles  are  supplied.  Dr.  Herringham  has  dealt  fully 
with  this  subject  in  his  account  of  the  minute  anatomy 
of  the  brachial  plexus.  The  following  is  his  account 
of  the  usual  composition  of  the  chief  nerves,  and  of 
the  usual  supply  of  the  chief  muscles.  (The  figures 
indicate  the  fifth,  sixth,  seventh,  and  eighth  cervical 
nerves,  and  the  first  dorsal  nerve.) 

Nerves. — Nerve  of  Bell,  5,  6,  7 ;  suprascapular,  5 
or  5,  6  ;  external  cutaneous,  5,  6,  7 ;  internal 
cutaneous,  1  or  8,  1  ;  nerve  of  Wrisberg,  1 ;  cir- 
cumflex, 5,  6 ;  median,  6,  7,  8,  1 ;  ulnar,  8,  9  ;  mus- 
culo-spiral,  6,  7,  8,  or  5,  6,  7,  8. 

Muscles,  3,  4,  5,  Lev.  anguli  scap. ;  5,  rhomboids ; 
5  or  5,  6,  biceps,  brachialis  ant.,  supra-  and  infra- 
spinatus,  teres  minor ;  5,  6,  deltoid,  subscapularis ;  0, 
teres  major,  pronator  teres,  flexor  carpi  rad.,  supin. 
longus  and  brevis,  superficial  thenar  muscles  ;  5,  6,  7, 
serratus  magnus ;  6  or  7,  extensores  carpi  rad.  ;  7, 


Chap,  xv.j         NERVES  OF  UPPER  LIMB.  283 

coraco-brachialis,  latiss.  dorsi,  extensors  at  back  of 
fore-arm,  outer  head  of  triceps ;  7,  8,  inner  head  of 
triceps ;  7,  8,  9,  flexor  sublimis,  flexores  profund.,  carpi 
uln.,  long,  poll.,  pronator  quad.  ;  8,  long  head  of 
triceps,  hypothenar  muscles,  interossei,  deep  thenar 
muscles. 

In  the  cutaneous  nerve  supply  of  tlie  fingers,  it 
must  be  remembered  that  on  the  palmar  aspect  the 
thumb,  the  two  outer  fingers,  and  the  radial  side  of 
the  ring  finger  are  supplied  by  the  median,  the 
remaining  one  and  a  half  fingers  by  the  ulnar  (Fig. 
29).  On  the  dorsal  aspect  the  thumb  is  supplied  by 
the  radial,  the  index  and  middle  fingers  are  supplied 
(as  far  as  the  base  of  the  second  phalanx)  by  the 
radial,  and  over  the  second  and  third  phalanges  by 
the  median.  The  little  finger  and  the  ulnar  side  of 
the  ring  finger  are  supplied  by  the  ulnar.  The 
radial  side  of  the  ring  finger,  as  far  as  the  base 
of  the  second  phalanx,  is  supplied  by  the  radial,  and 
the  rest  of  this  side  of  the  digit  by  the  median  (Fig. 
29).  The  cleft  between  the  middle  and  ring  fingers 
is  occasionally  supplied  by  the  ulnar,  or  partly  by  the 
ulnar  and  partly  by  the  radial. 

Injuries  to  the  main  nerves  of  the  upper 
limb. — The  entire  brachial  plexus  has  been  ruptured, 
leading  to  complete  paralysis  of  the  upper  limb.  In 
these  cases  it  would  appear  that  the  nerves  are  torn 
away  from  their  attachments  to  the  cord  rather  than 
broken  across  at  some  distance  from  it.  In  several 
instances  the  biceps  muscle  has  retained  some  of  its 
functions,  while  the  whole  of  the  other  muscles  have 
been  paralysed,  a  circumstance  perhaps  explained  by 
the  high  origin  of  the  bicipital  nerve  from  the  spinal 
cord. 

Paralysis  of  the  musculo-spiral  nerve. — 
When  complete,  the  hand  is  flexed  and  hangs  flaccid 
("  drop  wrist  "),  and  neither  the  wrist  nor  the  fingers 


SURGICAL  APPLIED  ANATOMY.     [Chap.  xv. 


M  X 


Fig.  29.— Cutaneous  Nerve  Supply  of  Upper  Limb. 

Anterior  aspect :  ],  Cervical  plexus;  2,  circumflex  ;  3,  ext.  cut.  of  muse,  spiral  ; 

4,  ext.  cutaneous  ;  5,  median  ;  6,  ulnar  ;  7,  int.  cutaneous  ;  8,  n.  of  Wrisljerg. 
Posterior  aspect:  1,  Cervical  plexus;  2,  circumflex;  3,  int.  cut.  of  muse,  spiral  : 

4,intercosto-humeral  ;  5,  n.  of  Wrisberg  ;  6,  int.  cutaneous;  7,  ext.  cut.  of 

inusc.  spiral ;  8.  ext.  cutaneous ;  9,  ulnar ;  10.  radial. 


Chap,  xv.j         NERVES  OF  UPPER  LIMB.  285 

can  be  extended.  The  latter  are  bent  and  cover  the 
thumb,  which  is  also  flexed  and  adducted.  When 
attempts  are  made  to  extend  the  fingers,  the  interossei 
and  lumbricales  alone  act,  producing  extension  of  the 
last  two  phalanges  and  flexion  cf  the  first.  Supi- 
nation  is  lost,  especially  if  the  elbow  be  extended  so 
as  to  exclude  the  action  of  the  biceps  muscle.  Ex- 
tension at  the  elbow  is  lost,  and  sensibility  is  dis- 
turbed over  the  skin  supplied  by  the  nerve  (Erb). 

Paralysis  of  the  median  nerve. — Flexion  of 
the  second  phalanx  is  impossible  in  every  finger,  as 
is  also  a  like  movement  of  the  last  joint  of  the  index 
and  middle  fingers.  Partial  flexion  of  the  third  pha- 
langes of  the  two  inner  digits  is  possible,  the  inner 
part  of  the  flexor  profundus  being  supplied  by  the 
nlnar  nerve.  Flexion  of  the  first  phalanx  with  exten- 
sion of  the  second  and  third  can  still  be  performed 
in  all  the  fingers  by  the  interossei.  The  thumb  is 
extended  and  adducted,  and  can  neither  be  flexed  nor 
opposed.  Bending  of  the  wrist  is  only  possible  when 
the  hand  is  forcibly  adducted  by  means  of  the  flexor 
carpi  ulnaris,  which  is  not  paralysed.  Pronation  is 
lost.  Sensation  is  disturbed  over  the  skin  supplied  by 
the  nerve  (Erb). 

Paralysis  of  the  ulnar  nerve. — Ulnar  flexion 
and  adduction  of  the  hand  are  limited.  Complete 
flexion  of  the  two  inner  fingers  is  impossible.  The 
little  finger  can  scarcely  be  moved  at  all.  The  action 
of  the  interossei  and  two  inner  lumbricales  is  lost. 
The  patient  is  unable  to  adduct  the  thumb,  and  sen- 
sibility is  impaired  over  the  cutaneous  area  supplied 
by  the  nerve  (Erb). 

After  complete  division  of  any  one  of  the  three 
great  nerves  of  the  upper  limb,  the  loss  of  sensation 
in  the  cutaneous  parts  supplied  by  that  nerve  is  often 
quite  slight.  This  is  accounted  for  by  the  interfacings 
that  occur  between  the  principal  nerves  of  the  arm,  so 


286  SURGICAL  APPLIED  ATJATOMY.     [Chap.  xv. 

that  when  a  given  trunk  is  injured  the  sensory  im- 
pressions are  returned  by  another  route.  Thus  are 
explained  those  cases  where  the  median  has  been 
sutured  after  accidental  division,  with  the  effect  that 
sensation  has  returned  to  the  cutaneous  parts  supplied 
by  the  nerve  within  a  few  hours.  Such  return  of 
sensation  is  probably  due  to  the  supplementary  action 
of  the  interlacing  nerve  fibres  bound  up  with  other 
trunks,  and  not  to  the  "  immediate  union  of  a  divided 
nerve,"  as  was  at  one  time  announced. 

Epipliyses  of  the  upper  limb. — The  epiphyses 
about  the  elbow  join  the  shafts  of  their  respective 
bones  at  17  years  (except  the  tip  of  the  internal 
condyle,  which  joins  at  18).  The  epiphyses  at  the 
shoulder  and  wrist  extremities  of  the  bones  join  at  20. 
The  nutrient  canals  of  the  three  bones  run  towards 
the  elbow.  The  nutrient  artery  of  the  humerus  comes 
from  the  brachial  or  infei-ior  profunda,  those  of  the 
radius  and  ulna  from  the  anterior  intei'osseous. 

The  nei-ve  supplying  the  humerus  is  the  external 
cutaneous.  The  radius  and  ulna  are(  supplied  by  the 
anterior  interosseous  of  the  median. 


287 


ABDOMEN    AND    PELVIS. 


CHAPTER   XVI. 

THE   ABDOMEN. 

THE  abdominal  parietes. — Surface  anatomy. 
—  The  degree  of  prominence  of  the  abdomen  varies 
greatly.  The  protuberance  of  the  belly  in  young 
children  is  mainly  due  to  the  relatively  large  size  of 
the  liver,  which  occupies  a  considerable  part  of 
the  cavity  in  early  life.  It  also  depends  upon  the 
small  size-  of  the  pelvis,  which  is  not  only  unable  to 
accommodate  any  abdominal  structure  (strictly  so- 
called),  but  can  scarcely  provide  room  for  the  pelvic 
organs  themselves.  Thus  in  infancy  the  bladder  and 
a  great  part  of  the  rectum  are  virtually  abdominal 
viscera.  After  long-continued  distension,  as,  for  ex- 
ample, after  pregnancy,  ascites,  etc.,  the  abdomen 
usually  remains  unduly  prominent  and  pendulous. 

In  examples  of  prolapse  of  the  mesentery  the 
upper  part  of  the  abdomen  becomes  sunken  in  and  the 
lower  part  unduly  prominent.  (See  page  326.) 

In  cases  of  great  emaciation  it  becomes  much  sunken, 
and  its  anterior  wall  appears  to  have  collapsed.  This 
change  is  most  conspicuous  about  the  upper  part  of  the 
region.  Here  the  anterior  parietes  immediately  below 
the  line  of  the  costal  cartilages,  instead  of  being  in  the 
same  plane  with  the  anterior  thoracic  wall,  may  so  sink 
in  as  to  be  almost  at  right  angles  with  that  wall  on  the 
one  hand,  and  with  the  lower  part  of  the  abdominal 
parietes  on  the  other.  In  such  cases  the  abdominal 
walls  just  below  the  thoracic  line  may  appear  to  be 
almost  vertical  when  the  patient  is  in  the  recumbent 


288  SURGICAL  APPLIED  ANATOMY.   [Chap.  xvi. 

posture.  This  change  of  surface  is  of  importance 
in  gastrostorny,  since  the  subjects  for  that  operation 
are  usually  much  emaciated,  and  the  incision  has  to  be 
made  close  below  the  costal  line. 

The  position  of  the  linea  alba  above  the  umbilicus 
is  indicated  by  a  slight  median  groove,  but  no  such 
indication  exists  below  the  navel.  The  linea  semi- 
lunaris  may  be  represented  by  a  slightly  curved  line 
drawn  from  about  the  tip  of  the  ninth  costal  car- 
tilage to  the  pubic  spine.  In  the  adult  it  would  be 
placed  about  three  inches  from  the  navel.  Above 
the  umbilicus  the  line  is  indicated  on  the  surface  by 
a  shallow  depression.  The  outline  of  the  rectus  can  be 
well  seen  when  the  muscle  is  in  action.  It  presents 
three  "linese  transversse,"  one  usually  opposite  the 
xiphoid  cartilage,  one  opposite  the  umbilicus,  and  a 
third  between  the  two.  The  two  upper  of  these  lines 
are  obvious  on  the  surface  in  well-developed  subjects. 

The  site  of  the  umbilicus  varies  with  the  obesity  of 
the  individual  and  the  laxity  of  l^he  abdomen.  It  is 
always  below  the  centre  of  the  line  between  the 
xiphoid  cartilage  and  the  pubes.  In  the  adult  it  is 
some  way  above  the  centre  of  the  body,  as  measured 
from  head  to  foot,  while  in  the  foetus  at  birth  it  is 
below  that  point.  It  corresponds  in  front  to  the  disc 
between  the  third  and  fourth  lumbar  vertebrae,  and 
behind  to  the  tip  of  the  third  lumbar  spinous  process. 
It  is  situated  about  three-quarters  of  an  inch  to  one 
inch  above  a  line  drawn  between  the  highest  points  of 
the  two  iliac  crests. 

The  anterior  superior  spine,  the  pubic  spine,  and 
Poupart's  ligament  are  all  conspicuous  and  important 
landmarks.  The  pubic  spine  is  nearly  in  the  same  hori- 
zontal line  with  the  upper  edge  of  the  great  trochanter. 
It  is  very  distinct  in  thin  subjects.  In  the  obese  it 
is  entirely  lost  beneath  the  pubic  fat.  In  such  indi- 
viduals, however,  it  can  be  detected,  when  the  subject  is 


chap,  xvi.]     THE  ABDOMINAL  PARIETES.  289 

a  male,  by  invaginating  the  scrotum  so  as  to  pass  the 
finger  beneath  the  subcutaneous  fat.  In  the  female  the 
position  of  the  process  may  be  made  out  by  adducting 
the  thigh  and  thus  making  prominent  the  tendon  of 
origin  of  the  adductor  longus  muscle.  This  muscle 
arises  from  the  body  of  the  pubes  immediately  below 
the  spine,  and  by  running  the  finger  along  the  muscle 
the  bony  prominence  may  be  reached.  If  the  finger  be 
placed  upon  the  pubic  spine  it  may  be  said  that  a 
hernia  descending  to  the  inner  side  of  the  finger  will 
be  inguinal,  while  one  presenting  to  the  outer  side 
will  be  femoral.  In  the  erect  position  of  the  body  the 
anterior  superior  spine  is  a  little  above  the  level  of  the 
promontory  of  the  sacrum,  while  the  tip  of  the  xiphoid 
cartilage  corresponds  to  about  the  lower  part  of  the 
tenth  dorsal  vertebra. 

In  that  part  of  the  back  which  corresponds  to 
the  abdominal  region  the  erector  spinae  masses  are 
distinct,  and  in  any  but  fat  subjects  their  outer 
edges  can  be  well  defined.  Between  these  masses 
is  the  spinal  furrow,  which  ends  below  in  an  angle 
formed  by  the  two  great  gluteal  muscles.  Immediately 
above  the  middle  of  the  crest  of  the  ilium  is  Petit's 
triangle,  or  the  gap  between  the  external  oblique  and 
latissimus  dorsi  muscles.  The  fourth  lumbar  spine 
is  about  on  a  level  with  the  highest  part  of  the  iliac 
crest  In  counting  the  ribs  it  is  well  to  commence 
from  above,  since  the  last  rib  may  not  project  beyond 
the  outer  edge  of  the  erector  spinae,  and  may  conse- 
quently be  overlooked. 

The  aorta  bifurcates  opposite  the  middle  of  the 
body  of  the  fourth  lumbar  vertebra  just  to  the  left  of 
the  middle  line.  This  spot  corresponds  very  nearly  to 
the  highest  point  of  the  iliac  crest,  and  will  therefore 
be  situate  about  three-quarters  of  an  inch  below  and  to 
the  left  of  the  umbilicus.  A  line  drawn  on  either  side 
from  the  point  of  bifurcation  to  the  middle  of  Pou part's 

T— 4 


290  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvi. 

ligament  will  correspond  to  the  course  of  the  common 
and  external  iliac  arteries.  The  first  two  inches  of 
this  line  would  cover  the  common  iliac,  the  remainder 
the  external. 

The  coeliac  axis  comes  off  opposite  the  lower  part 
of  the  twelfth  dorsal  vertebra,  at  a  spot  about  four  or 
five  inches  above  the  navel,  and  that  corresponds 
behind  to  the  twelfth  dorsal  spine.  The  superior 
mesenteric  and  suprarenal  arteries  are  just  below  the 
axis.  The  renal  vessels  arise  about  half  an  inch  below 
the  superior  mesenteric,  opposite  a  spot  some  3^ 
inches  above  the  umbilicus,  and  on  a  level  behind 
with  the  gap  between  the  last  dorsal  and  first  lumbar 
spines.  The  inferior  mesenteric  artery  comes  off"  from 
the  aorta  about  one  inch  above  the  umbilicus.  The 
deep  epigastric  artery  follows  a  line  drawn  from  the 
middle  of  Poupart's  ligament  to  the  umbilicus.  Along 
the  same  line  may  sometimes  be  seen  the  superficial 
epigastric  vein. 

The  abdominal  "  rings  "  will  be  referred  to  in  the 
paragraph  on  hernia. 

Anterior  abdominal  parietes. — The  skin 
over  the  front  of  the  abdomen  is  loosely  attached  in  the 
region  of  the  groin.  This  condition  is  taken  advantage 
of  in  certain  operations,  e.g.,  Wood's  procedure  for  the 
radical  cure  of  hernia.  It  also  allows  of  the  incision 
for  herniotomy  in  the  inguinal  region  being  made  by 
transfixing  a  fold  of  skin  that  has  been  pinched  up 
over  the  external  ring.  The  skin  is  more  adherent  to 
the  deeper  parts  in  the  middle  line  than  elsewhere,  but 
not  so  adherent  as  to  hinder  the  spread  of  inflammation 
from  one  side  of  the  abdomen  to  the  other.  In  cases 
of  great  obesity  two  transverse  creases  form  across 
the  belly,  one  crossing  the  umbilicus  and  the  other 
passing  just  above  the  pubes.  In  the  former  of  the 
two  creases  the  navel  is  usually  hidden  from  sight.' 
In  cases  of  anchylosed  hip-joints  transverse  creases  are 


Chap,  xvi.]     TUE  ABDOMINAL  PARIETES.  29 1 

often  noted  running  across  the  middle  of  the  belly. 
They  are  produced  by  the  freer  bending  of  the  spine, 
that  is  usually  permitted  in  anchylosis,  some  of  the 
simpler  movements  of  the  hip  joint  being  transferred  to 
the  column  when  the  articulation  is  rendered  useless. 

After  the  skin  has  been  stretched,  from  any  gross 
distension  of  the  abdomen,  certain  silvery  streaks 
appear  in  the  integument  over  its  lower  part.  They 
are  due  to  an  atrophy  of  the  skin  produced  by 
the  stretching,  and  their  position  serves  to  indicate 
the  parts  of  the  parietes  upon  which  distending 
forces  within  the  abdomen  act  most  vigorously. 
They  ai-e  well  seen  after  pregnancy,  ascites,  ovarian 
tumours,  etc. 

Beneath  the  skin  is  the  superficial  fascia,  which 
over  the  lower  half  of  the  abdomen  can  be  readily 
divided  into  two  layers.  The  great  bulk  of  the 
subcutaneous  fat  of  this  region  is  lodged  in  the  more 
superficial  of  the  two  layers.  In  cases  of  great  obesity 
the  accumulation  of  fat  is  perhaps  more  marked 
beneath  the  skin  of  the  abdomen  than  it  is  elsewhere. 
A  layer  of  fat  six  inches  in  depth  has  been  found  in 
this  region  in  cases  of  great  corpulence.  The  super- 
ficial vessels  and  nerves  lie  for  the  most  part  between 
the  two  layers  of  the  fascia,  so  that  in  obese  subjects 
incisions  may  be  made  over  the  abdomen  to  the  depth 
of  an  inch  or  so  without  encountering  blood-vessels  of 
any  magnitude. 

The  deep  layer  of  the  superficial  fascia  contains 
elastic  fibres,  and  corresponds  to  the  tunica  abdominalis 
or  "abdominal  belt"  of  animals.  It  is  attached  to 
the  deeper  parts  along  the  middle  line  as  far  as  the 
sy mphysis,  and  to  the-  fascia  lata  just  beyond  Poupart'a 
ligament.  In  the  interval  between  the  symphysis  and 
the  pubic  spine  it  has  no  attachment,  but  passes  down 
into  the  scrotum  and  becomes  the  dartos  tissue. 
Extravasated  urine  that  has  reached  the  scrotum  may 


292  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvi. 

mount  up  on  to  the  abdomen  through  this  interval,  and 
will  then  be  limited  by  the  deeper  layer  of  the  fascia. 
It  will  not  be  able  to  pass  down  into  the  thigh  on 
account  of  the  attachments  of  the  fascia,  nor,  for  a  like 
reason,  will  it  tend  to  pass  over  the  middle  lina  In 
the  same  way  emphysematous  collections  following 
injuries  to  the  chest,  when  beneath  the  deeper  layer 
of  the  fascia,  receive  a  check  at  the  groin,  and  lipomata 
also  that  grow  beneath  the  membrane  tend  to  be  limited 
by  the  middle  line  and  that  of  Poupart's  ligament. 

The  anterior  abdominal  parietes  vary  in  thick- 
ness in  different  subjects.  In  cases  of  emaciation  the 
outlines  of  some  of  the  viscera  may  be  readily  made 
out  or  even  seen  through  the  thinned  wall.  In  some 
cases  of  chronic  intestinal  obstruction  the  outlines 
of  the  distended  intestine  are  visible,  and  their  move- 
ments can  be  watched.  The  relative  thickness  of  the 
abdominal  wall  in  various  subjects  depends  rather 
upon  the  amount  of  the  subcutaneous  fat  than  upon 
the  thickness  of  the  muscles.  This  muscular  boundary 
affords  an  admirable  protection  to  the  viscera  within. 
By  contracting  the  abdominal  muscles  the  front  of  the 
belly  can  be  made  as  hard  as  a  board,  and  in  acute 
peritonitis  this  contraction  can  sometimes  be  seen  to 
produce  a  remarkable  degree  of  rigidity. 

A  blow  upon  the  abdomen  when  the  muscles  are 
firmly  contracted  will  probably  do  no  injury  to  the 
viscera  unless  the  violence  be  extreme.  The  rigid 
muscular  wall  acts  with  the  efficacy  of  a  dense  india- 
rubber  plate.  It  may  be  bruised  or  torn,  but  it  will 
itself  receive  the  main  shock  of  the  contusion. 

The  probable  effect  on  the  contained  viscera  of 
a  blow  upon  the  abdomen  will  depend  upon  many 
factors ;  but,  so  far  as  the  walls  themselves  are  con- 
cerned, the  effect  greatly  depends  upon  whether  the 
blow  was  anticipated  or  not,  and  upon  the  extent  of 
the  padding  of  fat  that  is  furnished  to  the  parietes. 


Chap,  xvi.]      THE  ABDOMINAL  PARIETES.  293 

If  the  blow  be  anticipated  the  muscles  of  the  belly 
will  be  instinctively  contracted,  and  the  viscera  be  at 
once  provided  with  a  firm  but  elastic  shield.  Thus 
the  abdominal  muscles  have  been  found  bruised  and 
torn  while  the  viscera  were  intact,  and,  on  the  other 
hand,  in  cases  probably  where  the  muscles  were  inert  or 
taken  unawares  a  viscus  has  been  found  to  be  damaged 
without  any  conspicuous  lesion  in  the  belly  wall. 

Along  the  linea  alba  the  abdominal  wall  is  thin, 
dense,  and  free  from  visible  blood-vessels.  Hence  in 
most  operations  upon  the  abdominal  cavity  the  incision 
is  made  in  the  middle  line.  Along  the  outer  border  of 
the  rectus  muscle  (i.e.  about  and  just  beyond  the  linea 
semilunaris)  the  parietes  are  also  thin  and  lacking  in 
vessels,  and  consequently  that  situation  is  well  suited 
for  an  incision.  There  are,  however,  few  operative 
circumstances  except  abdominal  nephrectomy  that  are 
met  by  an  incision  so  placed.  In  most  cases  it  is  a 
question  of  either  opening  the  abdomen  in  the  middle 
line  or  in  one  of  the  loins.  Below  the  navel  the  two 
recti  muscles  are  almost  in  contact,  and  here  the  linea 
alba  can  scarcely  be  said  to  exist.  Above  the  umbili- 
cus the  two  muscles  tend  to  separate  a  little,  and  the 
"  line  "  increases  greatly  in  width.  In  pregnancy  and 
in  other  forms  of  distended  abdomen  the  median 
interval  between  the  recti  may  be  much  increased. 

The  structures  immediately  behind  the  linea  alba 
are,  from  above  downwards,  the  liver,  stomach,  and 
transverse  colon  above  the  umbilicus,  and  the  small  in- 
testines and  bladder  (when  distended)  below  it.  There 
are  often  little  spaces  between  the  fibres  of  the  linea 
alba,  and  through  these  pellets  of  fat  from  the  sub- 
peritoneal  tissue  may  grow.  If  of  fair  size  these  little 
masses  may  be  mistaken  for  irreducible  herniae.  Similar 
growths  of  fat  may  extend  through  the  inguinal  or 
femoral  openings,  and  constitute  the  so-called  "  fatty 
herniae." 


294  SURGICAL  APPLIED  ANATOMY.  [Chap.  XVT. 

The  fibrous  ring  of  the  umbilicus  is  derived  from 
the  linea  alba.  To  this  ring  the  adjacent  structures, 
skin,  fasciae,  and  peritoneum,  are  all  closely  adherent. 
The  adhesion  is  such,  and  the  amount  of  tissue 
between  the  skin  and  peritoneum  is  so  scanty,  that  in 
operating  upon  an  umbilical  hernia  it  is  scarcely 
possible  to  avoid  opening  the  sac. 

In  the  foetus  three  vessels  enter  at  the  navel,  and 
immediately  separate  on  reaching  the  abdominal  cavity, 
the  vein  passing  directly  upwards  and  the  arteries 
obliquely  downwards.  Running  down  from  the  um- 
bilicus in  the  middle  line  is  also  the  remains  of  the 
urachus.  In  the  foetus,  the  spot  where  the  three 
vessels  part  company  is  about  the  centre  of  the  navel, 
and  it  thus  happens  that  in  a  congenital  umbilical 
hernia  the  gut  as  it  escapes  separates  the  three  vessels, 
which  become  to  some  extent  spread  over  it.  The 
congenital  hernia,  indeed,  works  its  way  in  among  the 
structures  of  the  cord  and  receives  its  main  coverings 
from  them.  These  hernise  are  fortunately  rare,  for  in 
certain  instances  they  extend  some  way  into  the  cord, 
and  in  at  least  two  reported  cases  the  gut  was  cut  across 
by  the  accoucheur  in  dividing  the  cord  at  birth.*  As 
the  abdomen  increases  in  height  the  contraction  of  the 
two  obliterated  arteries  and  of  the  urachus  drags  upon 
the  cicatrix  and  pulls  it  backwards  and  downwards. 
Thus,  in  the  adult  umbilical  ring,  as  viewed  from  the 
inner  side,  the  cords  representing  not  only  the  obli- 
terated arteries  and  the  urachus,  but  also  the  vein, 
appear  to  start  from  the  lower  border  of  the  cicatrix. 
In  adult  hernise,  indeed,  the  gut  escapes  above  both  the 
oblitei-ated  arteries  and  the  vein.  The  upper  half  of 
the  cicatrix  is  thin  when  compared  to  the  lower  half, 
and  is  "supported  also  by  less  firm  adhesions. 

*  The  congenital  hernia  must  be  distinguished  from  the  infantile 
umbilical  hernia  so  commonly  met  with  after  separation  of  the 
cord.  For  an  account  of  these  congenital  hernias,  see  paper  by  the 
author  in  the  Lancet,  vol.  i.,  1881,  p.  323. 


chap,  xvi.j     THE  ABDOMINAL  PARIETES.  295 

In  some  cases  a  fistula  is  found  at  the  navel  that 
discharges  urine.  This  is  due  to  a  patent  urachus. 
The  urinary  bladder  is  formed  by  a  dilatation  of  the 
stalk  of  the  allantois.  The  part  below  this  dilatation 
becomes  the  first  part  of  the  urethra,  that  above 
becomes  the  urachus.  In  one  instance  of  patent 
urachus  the  abnormal  opening  was  one  inch  in  diameter. 
The  patient,  a  man  aged  40,  had  a  stone,  which  was 
extracted  by  passing  the  finger  into  the  bladder  through 
the  opening  at  the  umbilicus. 

Sometimes  a  fistula  discharging  fseces  is  met  with 
at  the  navel  This  depends  upon  the  persistence  of  the 
vitello-intestinal  duct,  a  duct  that  at  one  time  connects 
the  rudimentary  intestine  with  the  yolk  sac,  and  that 
generally  disappears  without  leaving  any  trace.  The 
persistent  duct,  when  it  occurs,  is  known  as  Meckel's 
diverticulum,  and  springs  from  the  ileum  from  one 
to  four  feet  above  the  ileo-csecal  valve. 

The  position  of  the  transverse  intersections  of  the 
rectus  muscle  should  be  borne  in  mind.  They 
adhere  to  the  anterior  layer  of  the  rectus  sheath, 
but  not  to  the  posterior.  They  are  able,  therefore, 
in  some  extent  to  limit  suppurative  collections  and 
haemorrhages  beneath  the  sheath  on  its  anterior 
aspect.  This  muscle  is  often  the  seat  of  one  form  of 
"  phantom  tumour."  These  tumours  are  mostly  met 
with  in  the  hysterical  and  hypochondriac,  and  when 
associated  with  some  vague  abdominal  symptoms  are 
apt  to  mislead.  They  are  due  to  a  partial  contraction 
of  the  muscle,  usually  to  a  part  between  two  inter- 
sections, and  are  said  to  be  more  common  in  the  left 
rectus.  When  the  fibres  of  the  muscle  are  contracted 
the  "  tumour "  is  obvious,  but  when  they  relax  it 
disappears.  Other  phantom  tumours  depend  upon 
irregular  contraction  of  the  other  abdominal  muscles 
associated  with  flatulent  or  faeculent  distension  of  the 
bowel  In  great  distension  of  the  abdomen  the  fibres 


296  SURGICAL  APPLIED  ANATOMY.    [Cimp  xvi 

of  the  rectus  may  be  much  stretched,  since  they  bear 
the  brunt  of  the  distending  force.  The  direction  of 
the  fibres  also  renders  them  liable  to  be  torn  in  the 
opisthotonos,  or  extreme  arching  of  the  back,  of 
tetanus.  Portions  of  the  muscle  have  also  been 
ruptured  by  muscular  violence. 

The  lateral  muscles  of  the  front  abdominal  wall 
are  separated  from  one  another  by  layers  of  loose 
connective  tissue.  These  extensive  layers  favour 
the  spread  of  interstitial  abscesses  of  the  abdominal 
parietes.  Such  abscesses  will  be  guided  in  their 
course  by  the  attachments  of  the  muscles  between 
which  they  spread,  and  will  be  limited  by  the  semi- 
lunar  lines  in  front,  by  the  lower  parts  of  the  ribs  and 
their  cartilages  above,  by  Poupart's  ligament  and  the 
iliac  crest  below,  and  by  the  edge  of  the  erector 
cpinae  behind.  The  same  remark  applies  to  hsemorr- 
hagic  or  emphysematous  collections  between  these 
muscles. 

Between  the  abdominal  parietes  and  the  perito- 
neum is  a  layer  of  loose  connective  tissue,  the  sub- 
serous  connective  tissue.  The  looseness  of  this 
layer  greatly  favours  the  spread  of  abscess,  to  the 
progress  of  which  it  offers  little  resistance.  Such  an 
abscess  may  spread  from  the  viscera,  especially  from 
those  that  have  an  imperfect  peritoneal  covering,  as, 
for  example,  the  kidney,  the  vertical  parts  of  the  colon, 
etc.  The  laxity  of  this  tissue  is  of  great  service  in 
certain  surgical  procedures.  Thus  the  external  and 
common  iliac  arteries  can  be  reached  by  an  incision 
made  some  way  to  the  outer  side  of  the  vessels  and 
without  opening  the  peritoneum.  That  membrane 
having  been  exposed  in  the  lateral  wound,  the  artery 
is  reached  by  working  a  way  with  the  finger  through 
the  subperitoneal  tissue,  and  by  actually  stripping 
the  serous  membrane  from  its  attachments.  This 
condition  of  the  subserous  layer  also  favours  that 


chip,  xvi.]     THE  ABDOMINAL  PARIETES.  297 

stretching  of  the  peritoneum  which  occurs  under 
certain  circumstances. 

Wounds  of  the  abdomen  may  give  trouble  in 
their  treatment,  since,  when  inflicted,  they  may  open 
up  several  layers  of  fascia  and  so  lead  to  bagging  of 
pus  and  to  the  spread  of  suppuration  should  an  abscess 
follow  the  lesion.  When  the  more  muscular  parts 
are  divided  the  condition  of  the  layers  incised  is 
such  that  great  facilities  are  offered  for  the  em- 
bedding of  small  foreign  bodies,  such  as  pieces  of 
glass,  etc.,  which,  hidden  between  the  muscular  layers, 
may  well  be  overlooked.  Mr.  Pollock  records  a  case 
where  the  metal  part  of  a  steel  fork  with  two  prongs 
was  overlooked  and  allowed  to  remain  buried  in 
the  abdominal  walls  for  a  considerable  time. 

The  frequent  movement  of  the  belly  walls  does 
not  favour  that  rest  wlu'ch  is  so  essential  to  the  healing 
of  wounds. 

In  penetrating  wounds  the  contraction  of  the 
muscles  may  encourage  the  protrusion  of  the  viscera, 
especially  when  the  incision  is  transverse  to  the 
direction  of  the  muscular  fibres.  In  reducing  small 
portions  of  protruded  viscera  it  is  quite  possible  to 
push  them  into  one  of  the  connective  tissue  spaces 
between  the  muscles  or  into  the  subserous  tissue 
instead  of  into  the  peritoneal  cavity.  In  applying 
sutures  to  wounds  involving  the  whole  thickness  of 
the  parietes  it  is  necessary  that  the  threads  should 
include  the  peritoneum  so  that  early  healing  of  that 
membrane  may  be  brought  about  Without  such 
precaution  a  gap  may  be  left  in  the  surface  of  the 
peritoneum  which  would  favour  the  formation  of  a 
hernia  in  the  site  of  the  old  wound. 

Blood-vessels. — The  only  arteries  of  any  magni- 
tude in  the  abdominal  walls  are  the  two  epigastric 
arteries,  some  branches  of  the  deep  circumflex  iliac, 
.  the  last  two  intercostal  vessels,  the  epigastric  branch 


298  SURGICAL  APPLIED  ANATOMY.    [Chap.  xvi. 

of  the  internal  mammary,  and  the  abdominal  divisions 
of  the  lumbar  arteries.  The  superficial  vessels  are 
of  small  size,  although  Verneuil  reports  a  case  of 
fatal  haemorrhage  from  the  superficial  epigastric 
vessel. 

The  superficial  veins  on  the  front  of  the  abdomen 
are  numerous,  and  are  very  distinct  when  varicose. 
A  lateral  vein,  extending  from  the  axilla  to  the  groin, 
uniting  the  axillary  and  femoral  veins,  is  often 
rendered  in  this  way  very  prominent.  The  sur- 
face abdominal  veins  may  take  no  part  as  alternative 
blood  channels  in  cases  of  obstruction  of  the  inferior 
vena  cava.  Clinical  experience  shows  that  these  veins 
may  be  also  enormously  varicose  in  instances  where 
the  inferior  cava  is  qiiite  patent.  In  one  case  under 
my  care  there  was  extensive  varicosity  of  the  surface 
veins  from  the  pectoral  region  to  the  groin  that  in- 
volved one  side  of  the  body  only.  It  has  been  shown, 
moreover,  that  the  valves  of  these  vessels  are  so 
arranged  that  the  blood  in  the  surface  veins  above  the 
navel  goes  to  the  axilla,  while  that  in  the  veins  of  the 
subumbilical  region  runs  to  the  groin. 

SchifF  has  shown  that  certain  small  veins  con- 
nect the  portal  vein  with  the  epigastric  veins  at  the 
umbilicus. 

As  regards  the  surface  lymphatics  of  the  front  of 
the  abdomen,  it  may  be  said  in  general  terms  that 
those  above  the  umbilicus  go  to  the  axillary  glands, 
and  those  below  to  the  glands  of  the  groin. 

Nerves. — The  abdominal  wall  is  supplied  by  the 
lowest  seven  dorsal  or  intercostal  nerves,  and  by  the 
first  two  lumbar  nerves.  These  nerves  run  obliquely 
to  the  long  axis  of  the  abdomen  downwards  and 
inwards  from  the  sides  to  the  middle  line.  Their 
direction  is  represented  by  a  continuation  of  tho 
lines  of  the  ribs  :  they  are  placed  parallel  to  one 
another  and  at  fairly  equal  distances  apart.  It  ia 


Chap,  xvi.]     THE  ABDOMINAL  PARIETES.  299 

important  to  note  that  they  supply  not  only  the 
abdominal  integument,  but  also  the  imiscles  of  the 
belly,  viz.,  the  rectus,  the  two  oblique  muscles,  and 
the  transversalis.  This  association  is  of  great  prac- 
tical importance.  If  a  cold  hand  be  suddenly  placed 
upon  the  belly  the  muscles  at  once  contract  and  the 
abdomen  is  instinctively  rendered  rigid.  The  safety 
of  the  viscera,  so  far  as  at  least  protection  from 
contusions  is  concerned,  depends  upon  the  readiness 
with  which  the  muscles  can  contract  at  the  first 
indication  of  danger.  As  has  been  already  stated,  the 
viscera  have  a  very  efficient  protection  against  the 
effects  of  blows  when  the  belly  muscles  are  in  a  state 
of  rigid  contraction.  The  sensitive  skin  acts  the  part 
of  a  sentinel,  and  the  intimate  association  of  the  surface 
nerves  with  the  muscular  nerves  allows  the  warnings 
of  this  sentinel  to  be  readily  given  and  immediately 
acted  upon.  If  the  skin  and  the  muscles  had  each 
an  independent  nerve-supply,  a  longer  interval  would 
elapse  between  the  warning  to  the  skin  and  the 
muscular  contraction  than  occurs  when  those  two 
parts  are  both  supplied  by  the  same  nerves.  The 
rigidity  of  the  muscles  in  certain  painful  affections  of 
the  skin  over  the  abdomen  is  often  very  conspicuous. 
[  might  instance  the  case  of  a  man  with  a  burn  over  the 
belly.  While  the  burn  is  protected  by  the  dressings 
the  abdominal  muscles  are  lax  and  the  parietes  move 
with  the  respiratory  act.  The  moment  the  dressings 
are  removed,  the  sin-face  becoming  painful,  the 
muscles  at  once  contract  and  the  belly  becomes 
rigid.  It  will  be  noticed  that  seven  of  the  abdominal 
nerves  supply  intercostal  muscles,  and  are  thus 
intimately  associated  with  the  movements  of  respira- 
tion. The  abdominal  muscles  are  of  course  concerned 
in  the  same  movements.  These  associations  are  illus- 
trated when  cold  water  is  suddenly  dashed  upon  the 
belly.  The  subject  of  such  experiment  at  once 


300  SURGICAL  APPLIED  ANATOMY,   tchap.  xvi. 

experiences  a  violent  respiratory  movement  in  the 
form  of  a  deep  gasp.  When  the  abdominal  muscles 
are  firmly  fixed  the  lower  ribs  are  also  rigid,  and 
respiration  is  limited  to  the  higher  ribs  and  to  the 
thorax  proper. 

There  are  other  practical  points  about  these  nerves. 
In  caries  of  the  spine,  and  in  certain  injuries  to  the 
column,  the  spinal  nerves  may  suffer  injury  as  they 
issue  from  the  vertebral  canal.  This  injury  may  show 
itself  by  modified  sensation  in  the  parts  supplied  by 
such  nerves.  Thus  in  Pott's  disease  the  patient  often 
complains  of  a  sense  of  tightness  about  the  abdomen, 
as  if  a  cord  were  tied  around  it.  This  sense  of 
constriction  depends  upon  an  impaired  sensation  in  the 
parts  supplied  by  a  certain  pair  of  nerves ;  or,  if  the 
sense  of  constriction  be  wider  spread,  by  two  or  more 
pairs  of  nerves.  In  other  cases  a  sense  of  pain  may 
take  the  place  of  that  of  constriction.  It  would  hardly 
be  believed  that  spinal  disease  has  been  mistaken  for 
"  belly-ache."  But  many  such  cases  have  been  recorded. 
A  child  complains  of  pain  over  the  pit  of  the  stomach 
or  about  the  umbilicus,  and  this  feature  may  quite 
absorb  for  a  while  the  surgeon's  attention.  The 
abdomen  is  carefully  poulticed,  while  the  only  mischief 
is  in  the  vertebral  column.  Other  symptoms,  however, 
develop,  and  it  becomes  evident  that  the  pain  is 
due  to  pressure  upon  the  nerves  supplying  the  skin 
over  the  epigastric  or  umbilical  regions,  and  that  that 
pressure  is  a  circumstance  in  the  course  of  spinal  bone 
disease.  The  site  of  the  painful  part  depends,  of 
course,  upon  the  position  of  the  spinal  ailment,  and 
thus  the  cutaneous  symptoms  may  serve  to  localise 
the  caries  in  the  vertebrae.  Thus  the  skin  over  the 
"  pit  of  the  stomach "  is  supplied  by  the  sixth  and 
seventh  dorsal  nerves,  the  tenth  nerve  is  nearly  in  a 
line  with  the  umbilicus,  while  the  two  lumbar  nerves 
run  close  above  Poupart's  ligament.  The  position  of 


Chap,  xvi.)     THE  ABDOMINAL  PARIETES.  301 

the  intermediate  trunks  can  be  readily  estimated. 
Pain  referred  to  districts  supplied  by  the  lower  ab- 
dominal nerves  in  connection  with  spinal  caries  may 
mislead  the  surgeon  from  the  real  seat  of  the  malady, 
and  may  arouse  a  suspicion  of  mischief  in  the  kidneys 
or  bladder. 

It  may  be  noted  that  some  of  these  nerve  disturb- 
ances, especially  the  sense  of  a  constricting  band, 
are  common  in  certain  affections  of  the  spinal  cord, 
such  as  locomotor  ataxia,  etc. 

These  nerves  of  the  belly-wall  have  still  more 
important  associations.  Not  only  are  they  supplied 
to  the  skin  of  the  abdomen,  and  to  the  abdominal 
muscles,  but  they  also  share  in  the  nerve  supply  of  the 
abdominal  contents.  It  is  well  known  that  the  most 
conspicuous  supply  of  the  abdominal  viscera  is  derived 
from  the  sympathetic.  This  nerve  cord  receives  many 
contributions  from  the  spinal  nerves,  and  the  mixed 
trunks  thus  formed  are  distributed  to  the  various 
organs.  It,  however,  happens  that  that  segment  of 
the  gangliated  cord  of  the  sympathetic  that  is  within 
the  abdomen  (viz.  the  lumbar  segment)  has  practically 
nothing  to  do  with  the  strictly  abdominal  viscera. 
The  lumbar  cord  communicates  with  the  lumbar 
nerves,  but  only  two  of  these  have  any  concern 
with  the  abdominal  parietes,  and  that  concern  is  of 
very  insignificant  extent,  and  relates  rather  to  the 
pelvic  than  to  the  abdominal  parts  of  the  parietes. 
The  spinal  nerves  mostly  concerned  with  the  belly- 
wall  are  the  last  seven  doi-sal.  These  nerves  have 
communication  with  the  lower  seven  sympathetic 
ganglia  in  the  thorax,  and  it  is  to  the  thoracic  sympa- 
thetic that  we  must  look  for  some  more  direct  interest 
in  the  abdominal  nerve-supply  so  far  as  it  affects  the 
viscera.  This  connection  is  afforded  by  the  splanchnic 
nerves  that  come  off  from  the  lower  seven  or  eight 
thoracic  ganglia,  and  are  in  communion  with  the 


302  SURGICAL  APPLIED  ANATOMY,   icnap.  xvr. 


very  nerves  that  supply  the  parietes.*  These 
nerves  go  to  the  great  plexuses  that  provide  the 
nerve  supply  for  the  abdominal  viscera,  to  the  great 
solar  plexus,  and  to  some  of  those  more  or  less 
directly  derived  from  it.  Without  some  such  expla- 
nation it  is  difficult  to  understand  why  the  sympa- 
thetic supply  of  the  abdominal  organs  should  be 
derived  from  a  nerve  cord  half  way  up  in  the  thorax, 
when  that  very  cord  extends  into  the  abdomen  itself, 
and  could  provide  a  much  more  direct  supply.  This 
nerve  relationship  is  illustrated  in  disease  in  many 
ways.  Thus,  in  acute  peritonitis  and  in  laceration  of 
certain  of  the  viscera  the  abdominal  muscles  become 
rigidly  contracted,  so  as  to  insure  as  complete  rest  as 
possible  to  the  injured  parts.  In  acute  peritonitis 
the  belly  is  very  hard,  the  respirations  are  purely 
thoracic,  and  so  entirely  do  the  cutaneous  portions  of 
these  nerves  enter  into  the  situation,  that  the  patient 
is  often  unable  to  tolerate  even  the  most  trifling 
pressure  upon  his  abdomen. 

Congenital  deformities  of  the  abdomen.  - 
In  the  foetus  the  intestinal  canal  is  cut  off  from  the 
yolk  sac  by  the  gradual  growth  of  the  ventral  plates 
and  their  ultimate  union  in  the  middle  line.  This 
union  occurs  latest  at  the  umbilicus,  and  when 
complete  the  abdominal  cavity  is  entirely  enclosed. 
In  some  cases  of  imperfect  development  the  anterior 
abdominal  wall  is  more  or  less  entirely  absent,  and 
the  viscera  are  either  entirely  uncovered  or  protected 
only  by  a  scanty  membrane.  This  condition  is  usually 
associated  with  other  defoi-mities,  which  are  incon- 
sistent with  any  but  very  brief  existence.  In  many 

*  Beck  (Phil.  Trans.,  1846)  and  others  state  that  the  great' 
splanchnic  nerve  is  in  connection  with  the  upper  as  well  as  with 
the  lower  thoracic  ganglia,  and  such  a  connection  would  place  the 
abdominal  viscera  in  relation  with  a  still  larger  number  of  respi- 
ratory muscles,  and  would  further  support,  the  interest  of  those 
viscera  in  the  respiratory  movements  generally. 


Chap,  xvi.]  HERNIA.  303 

cases  the  abdominal  walls  are  fairly  complete,  but 
there  is  a  lack  of  union  in  the  middle  line  about  the 
umbilicus.  Thus  result  the  various  forms  of  con- 
genital exomphalos,  which  may  vary  in  severity  from 
a  small  hernia  to  a  protrusion  of  the  whole  of  the 
more  moveable  viscera.  One  of  the  most  remarkable 
deformities  is  that  known  as  extroversion  of  the 
bladder.  Here,  not  only  is  a  part  of  the  belly  wall 
absent,  but  also  a  part  of  the  genito-urinary  apparatus. 
In  complete  cases  there  is  an  absence  of  the  umbilicus 
and  of  the  anterior  abdominal  wall  below  it.  There  is 
no  symphysis  pubis,  an  absence  of  the  anterior 
wall  of  the  bladder,  of  the  principal  part  of  the  penis, 
and  the  whole  of  the  roof  of  the  urethra.  The 
scrotum,  also,  as  may  be  expected  from  a  reference  to 
the  development  of  that  part,  is  bifid. 

Hernia. — 1.  Inguinal  hernia. — In  this  form  of 
rupture  the  herniated  bowel  occupies  the  inguinal 
canal  for  the  whole  or  part  of  its  entire  length.  This 
canal  runs  obliquely  from  the  internal  to  the  external 
abdominal  ring,  and  is  about  one  and  a  half  inches  in 
length.  It  represents  the  track  followed  by  the  testis 
in  its  descent.  It  is,  in  a  sense,  a  passage  right  through 
the  abdominal  walls,  and  is  occupied  by  the  spermatic 
cord.  It  is  not  a  free  canal,  however,  in  the  same 
sense  as  one  would  speak  of  an  open  tube,  but  is  rather 
a  potential  one,  a  tract  of  tissue  so  arranged  as  to 
permit  of  a  body  being  thrust  along  it.  It  is  a  breach 
in  the  abdominal  wall,  not  a  doorway ;  a  breach 
that  is  forcibly  opened  up  and  widened  in  the  acquired 
forms  of  hernia.  When  a  hernia  occupies  the  in- 
guinal canal  it  is  covered  in  front  by  the  integuments, 
the  external  oblique  aponeurosis,  and  the  lower  fibres 
of  the  internal  oblique  and  transversalis  muscles.  It 
rests  behind  upon  the  transversalis  fascia,  the 
conjoined  tendon,  and  the  triangular  ligament ;  over 
it  arches  the  transverse  and  internal  oblique 


304  SURGICAL  APPLIED  ANATOMY.   [Chap. XVL 

muscles,  while  below  it  is  the  angle  formed  by 
the  union  of  Poupart's  ligament  with  the  transver- 
salis  fascia.  The  herniated  bowel  is  contained  within 
a  "  sac,"  which  is  always  formed  of  peritoneum.  In 
congenital  hernia  the  sac  exists  already  formed  in  the 
form  of  an  abnormally  patent  "processus  vaginalis." 
In  acquired  herniae  the  sag  consists  of  that  part  of  the 
parietal  peritoneum  which  the  gut  pushes  before  it  in 
its  descent. 

The  external  abdominal  ring  is  readily  felt  by 
invaginating  the  scrotum  with  the  point  of  the  finger, 
and  then  passing  the  digit  up  in  front  of  the  cord. 
If  the  nail  be  kept  against  the  cord  the  pulp  of  the 
finger  can  readily  recognise  its  triangular  slit-like 
opening.  Under  ordinary  circumstances  in  adults  it 
will  just  admit  the  tip  of  the  little  finger.*  The 
internal  ring  is  situate  about  half  an  inch  above  the 
middle  of  Poupart's  ligament. 

There  are  two  principal  forms  of  inguinal  hernia, 
which  can  be  best  understood  by  a  view  of  the  anterior 
abdominal  parietes  from  within.  From  such  an  aspect 
it  will  be  seen  that  the  peritoneum  is  marked  by  three 
linear  ridges  that  run,  roughly  speaking,  from  the 
umbilicus  to  the  pelvic  brim.  One  of  these  ridges 
follows  the  middle  line  from  the  navel  to  the  syinphysis, 
and  represents  the  urachus;  a  second,  that  may  be 
indicated  by  a  line  drawn  from  the  middle  of  Poupart's 
ligament  to  the  navel,  represents  the  deep  epigastric 
artery  ;  while  between  these  two,  and  much  nearer  to 
the  epigastric  vessel  than  to  the  middle  line,  is  the  line 
formed  by  the  obliterated  hypogastric  artery.  By 
means  of  these  ridges  the  peritoneum  is  made  to  pre- 
sent three  fossae,  an  external  to  the  outer  side  of  the 

*  In  cases  of  congenital  or  acquired  absence  of  the  cord  the 
external  ring  may  be  almost  obliterated.  Paulet  quotes  from 
Malgaigne  the  case  of  an  old  man  whose  testicle  had  been  removed 
in  infancy  and  in  whom  the  external  ring  was  so  small  as  to  be 
scarcely  recognisable. 


Chap,  xvi.i  HERNIA.  305 

epigastric  nrtery,  an  internal  between  the  urachus 
and  the  hypogastric  artery,  and  a  middle  between  the 
tract  of  the  latter  vessel  and  the  epigastric  trunk. 
The  internal  ring  (so  called)  is  just  to  the  outer  side 
of  the  epigastric  artery,  and  the  site  of  the  summit  of 
the  inguinal  canal  is  indicated  by  a  depression  in  the 
peritoneum.  When  a  hernia  follows  the  inguinal 
canal  throughout  its  entire  length,  it  is  called  oblique, 
indirect,  or  external;  "oblique"  or  "indirect"  from 
its  taking  the  oblique  direction  of  the  canal,  "external" 
from  the  position  of  its  neck  with  reference  to  the 
epigastric  vessel.  The  coverings  of  such  a  hernia 
would  be  the  same  as  those  of  the  cord,  viz.,  the  skin, 
the  superficial,  intercolumnar,  cremasteric  and  infundi- 
buliform  layers  of  fascia,  the  subserous  tissue,  and 
the  peritoneum.  When  the  hernia  escapes  to  the 
inner  side  of  the  deep  epigastric  artery,  through  the 
space  known  as  Hesselbach's  triangle,  it  is  called  a 
direct  or  internal  hernia  for  reasons  that  will  be 
obvious.  There  may  be  two  forms  of  direct  hernia.  In 
one  form  the  gut  escapes  through  the  middle  fossa 
above  described,  in  the  other  through  the  inner  fossa 
between  the  hypogastric  artery  and  the  outer  edge  of 
the  rectus  muscle.  The  middle  fossa  is  nearly  oppo- 
site to  the  summit  of  the  external  ring.  A  hernia 
escaping  through  that  fossa  would  enter  the  inguinal 
canal  some  little  way  below  the  point  of  entrance  of 
an  oblique  hernia,  and  would  have  the  same  coverings 
as  that  hernia,  with  the  exception  of  the  infundibuli- 
form  fascia.  The  first  covering,  indeed,  that  it  would 
receive  from  the  canal  structures  would  be  the  cre- 
masteric fascia.  The  inner  fossa  corresponds,  so  far 
as  the  inguinal  canal  is  concerned,  with  the  external 
ring.  A  hernia  escaping  through  this  fossa  would  be 
resisted  by  the  conjoined  tendon  and  the  triangular 
ligament.  These  structures  are  either  stretched  over 
the  hernia  so  as  to  form  one  of  its  coverings,  or  the 

u— 4         *  x 


306  SURGICAL  APPLIED  ANATOMY.   [Chap.  xvi. 

conjoined  tendon  is  perforated  by  the  hernia,  or  lastly 
the  gut  deviates  a  little  in  an  outward  direction  so  as 
to  avoid  the  tendon  and  appear  at  its  outer  side 
(Velpeau).  In  any  case  the  hernia  is  forced  almost 
directly  into  the  external  abdominal  ring.  The 
coverings  of  such  hernise  are  the  skin  and  superficial 
fascia,  the  intercolumnar  fascia,  the  triangular  liga- 
ment and  conjoined  tendon  (with  the  exceptions  above 
mentioned),  the  transversalis  fascia,  subserous  tissue, 
and  peritoneum. 

An  examination  of  the  abdominal  wall,  apart  from 
clinical  experience,  would  lead  one  to  suspect  that  the 
direct  hernia  would  be  more  common  than  the  indirect, 
since  the  parietes  are  certainly  less  resisting  opposite 
Hesselbach's  triangle  than  they  are  in  the  parts  imme- 
diately external  to  the  epigastric  artery.  Indeed,  just 
to  the  outer  side  of  the  conjoined  tendon  the  belly  wall 
is  remarkably  thin.  These  conditions,  however,  seem 
to  offer  less  facilities  for  the  escape  of  a  hernia  than 
does  the  inguinal  canal  itself.  The  funnel-shaped 
depression  in  the  peritoneum  at  the  summit  of  that 
canal  seems  to  offer  particular  inducements  for  rupture, 
and  there  are,  besides,  certain  congenital  defects  in  the 
vaginal  process  of  the  peritoneum  that  render  hernia 
almost  unavoidable  along  the  inguinal  canal. 

Direct  versus  indirect  inguinal  hernia. — 
The  indirect  hernia,  as  just  hinted,  may  be  congenital, 
the  direct  is  never  congenital  In  the  congenital 
oblique  hernia  the  outline  of  the  inguinal  canal  and 
the  relations  of  the  various  parts  concerned  are  but 
little  disturbed,  and  the  differences  between  this 
form  of  rupture  and  the  direct  variety  are  conspicuous. 
The  acquired  oblique  hernia,  however,  does  not  present 
such  a  contrast  to  the  direct  form  as  may  be  expected. 
In  the  first-named  rupture,  from  constant  dragging 
upon  the  parts  the  internal  ring  becomes  more  or  less 
approximated  to  the  external  ring,  and  the  length  of 


Chap,  xvi.]  HERNIA.  307 

the  canal  and  consequently  the  obliquity  of  the  hernia 
are  considerably  reduced.  Thus  the  axes  of  the  two 
forms  of  rupture  do  not  present  such  differences  as  to 
make  their  nature  at  once  obvious.  The  direct  hernia, 
however,  on  reduction,  will  pass  directly  back  into  the 
belly,  while  the  indirect  will,  even  in  old  cases,  take  a 
slight  but  appreciable  direction  outwards.  After  the 
reduction  of  the  direct  hernia,  the  edge  of  the  rectus 
muscle  may  be  readily  felt  to  the  inner  side  of  the  aper- 
ture, and  the  pulsation  of  the  epigastric  artery  will 
probably  be  detected  on  its  outer  side,  features  that 
are  both  lacking  in  the  oblique  variety.  From  the 
slight  inducement  offered  to  its  progress,  and  from  its 
insignificant  neck,  the  direct  hernia  is  usually  small 
and  globular,  while  for  opposite  reasons  the  oblique 
rupture  may  attain  large  size>  and  tends  to  assume  a 
pyriform  outline. 

Forms  of  oblique  hernia  depending;  upon 
congenital  defects  in  the  "  vaginal  process.'1 
The  descent  of  tfie  testis. — It  is  well  known  that  the 
testis  in  the  foetus  descends  from  the  region  of  the 
kidney  into  the  scrotum  by  making  a  way  through  the 
abdominal  wall  that  is  afterwards  known  as  the  in- 
guinal canal. 

Its  descent  is  preceded  by  the  passage  into  the 
scrotum  of  a  process  of  the  peritoneum,  the  vaginal 
process.  The  testicle  usually  enters  the  internal  ring 
about  the  seventh  month  of  foetal  life,  and  by  the 
eighth  month  is  in  the  scrotum.  The  testis  is  guided 
to  its  final  resting  place  by  the  gubernaculum,  a  band 
of  muscular  fibres.  This  band  is  attached  below  to 
the  anterior  abdominal  parietes,  to  the  pubes  near  the 
root  of  the  penis,  to  the  bottom  of  the  scrotum,  and  to 
"the  tuber  ischii  and  sphincter  ani  (Lockwood).  The 
last  named  attachments  serve  to  explain  the  occasional 
passage  of  the  testis  beyond  the  scrotum  into  the 
perineum  (testis  in  perineo).  In  one  example  of  this 


3^8  SURGICAL  APPLIED  ANATOMY.    [Chap.  xvi. 

condition  I  found  it  necessary  to  divide  a  band  passing 
from  the  tuber  ischii  to  the  testis  before  I  could  place 
the  gland  in  the  scrotum. 

Following  the  gubernaculum  upwards,  it  is  attached, 
first  of  all,  to  the  vaginal  process,  which,  therefore, 
descends  before  the  testis,  then  to-  the  gland  and 
epididymis,  and,  lastly,  to  the  peritoneum  about  the 
bowel  (caecum,  ileum,  or  mesentery  on  the  right  side, 
and  sigmoid  flexure  on  the  left  side).  The  latter  connec- 
tions serve  to  explain  the  condition  of  infantile  hernia, 
in  which  a  bag  or  diverticle  of  peritoneum  is  drawn 
down  into  the  scrotum  after  the  testis  (Lockwood). 
This  diverticle  can  then  become  the  sac  of  a  hernia. 

The  vaginal  process  is  often  found  open  at  birth, 
but  it  is  more  usually  found  cut  off  from  the  peritoneal 
cavity,  the  portion  thus  isolated  forming  the  tunica 
vaginalis.  This  vaginal  process  will  have  a  narrowed 
part  or  neck,  as  it  passes  along  the  inguinal  canal,  and 
will  be  free  to  enlarge  again  on  reaching  the  scrotum. 
The  manner  in  which  it  is  cut  off  is  as  follows.  It 
becomes  obliterated  in  two  places,  at  the  internal  ring 
and  at  a  spot  just  above  the  epididymis,  the  obliteration 
usually  beginning  at  the  higher  point  first.  Supposing 
obliteration  to  have  taken  place  at  these  two  points, 
the  vaginal  process  between  them  will  be  represented 
by  an  isolated  tube.  This  soon  shrinks,  closes,  and 
dwindles  to  an  insignificant  fibrous  cord.  It  may, 
however,  remain  patent  in  part,  and  if  fluid  accumu- 
lates in  this  patent  portion,  an  "  encysted  hydrocele  of 
the  cord  "  is  produced.  As  regards  the  mode  of  closure, 
three  contingencies  may  happen,  each  giving  rise  to  a 
particular  form  of  hernia:  (1)  The  "process"  may  not 
close  at  all ;  (2)  it  may  close  at  the  upper  point  only  ; 
and  (3)  it  may  close  at  the  lower  point  only. 

(1)  When  the  vaginal  process  is  entirely  open,  gut 
can  readily  descend  at  once  into  the  scrotum.  Such  a 
condition  is  called  a  congenital  hernia.  Here  the 


chap,  xvi.]  HERNIA  309 

intestine  is  found  to  occupy  a  large  sac  of  the  peri- 
toneum, the  open  orifice  of  which  is  placed  at  the  in- 
ternal inguinal  ring.  The  neck  of  the  sac  is  long  and 
narrow,  the  parts  around  have  not  been  disturbed  to 
perinil  the  bowel  to  pass,  and  the  actual  sac  itself  is 
very  thin.  It  is  on  account  of  these  anatomical  con- 
ditions that  the  effects  of  strangulation  fall  as  a  rule 
heavier  upon  this  form  of  hernia  than  upon  the  corre- 
sponding acquired  form. 

(2)  When  the  process  is  closed  only  at  the  internal 
ring  the  unduly  large  tunica  vaginalis  is  found  to  ex- 
tend up  to  that  orifice.     Behind  this  abnormal  tunica  a 
diverticle  of  peritoneum  is  drawn  down  into  the  scrotum 
by  the  gubernaculum,  and  becomes  the  sac  of  a  hernia 
(Lockwood).     This  is  known  as  an  infantile  or  en- 
cysted hernia.     In  such  a  case  the  abnormal  tunica 
vaginalis  lies  in  front  of  the  sac,  and  therefore  three 
layers  of  peritoneum  would  have  to  be  cut  through  be- 
fore the  gut  could  be  reached.     The  term  "  infantile  " 
was  given  to  this  rupture  because  the  first  cases  re- 
ported were  met  with  in  infants  ;  the  term  "encysted," 
because  the  hernial  sac  was  considered  to  be  enclosed  by 
the  sac  of  the  tunica  vaginalis.    The  condition  of  parts 
that  favours  the  development  of  this  rupture  serves  also 
to  explain  those  anomalous  cases  of  congenital  hernia 
that  appear  suddenly  and  for  the  first  time  in  adult 
life.     Here,  under  some  unwonted  exertion  the  peri- 
toneum that  separates  the  large  tunica  vaginalis  from 
the  general  peritoneum  at  the  internal  ring  gives  way, 
and  the  gut  at  once  passes  into  the  cavity  beyond,  and 
so  appears  in  the  condition  of  a  congenital  hernia. 

The  infantile  hernia  must  also  include  cases  in 
which  the  sac  descends  behind  an  entirely  unclosed 
vaginal  process. 

(3)  In  the  last-named  circumstance  a  tubular  pro- 
cess of  peritoneum  leads  down  as  far  as  the  top  of  the 
testicle,  and  there  ends,  the  normal  tunica  vaginalis 


310  SURGICAL  APPLIED  ANATOMY.   [Chap.  xvi. 

being  beyond.     Hernia  into  this  process  is  called  a 
hernia  into  the  funicular  process. 

In  the  first  of  these  forms  the  testicle  is  quite 
enveloped  in  the  hernia.  In  the  second  and  third 
forms,  as  well  as  in  the  acquired  form,  it  is  to  be  felt 
quite  distinct  from  the  rupture,  being  actually  behind 
and  below  it.  A  congenital  hernia  may  form  in  cases 
where  the  testicle  has  not  descended  at  all.  In  such 
instances  the  vaginal  process  may  occupy  the  would-be 
canal,  and  along  this  process  a  hernia  may  descend.  It 
is  well  known  that  the  testicle  may  make  its  first  ap- 
pearance in  the  scrotum,  months  and  even  years  after 
birth.  In  such  cases  the  vaginal  process  may  be 
normally  developed  at  birth  (i.e.  may  occupy  the 
scrotum),  or  it  may  be  abortive. 

In  the  foetus  the  inguinal  canal  is  relatively 
much  shorter  than  it  is  in  the  adult.  As  the  pelvis 
develops,  however,  the  relations  of  the  canal  approach 
more  to  the  normal.  In  the  congenital  hernia  the 
relations  of  the  canal  are  not  disturbed  as  they  are 
in  the  acquired  form.  Thus,  it  happens  that  such 
ruptures  have  long  and  narrow  necks,  and  the  difficulty 
in  steadying  this  neck  constitutes  one  of  the  special 
obstacles  in  the  effectual  reduction  of  the  hernia. 

There  is  another  possible  congenital  defect  that  may 
predispose  to  hernia,  viz.  an  abnormally  long  mesentery. 
If,  in  the  dead  subject,  the  inguinal  canal  be  opened  up, 
and  an  attempt  made  to  draw  a  piece  of  gut  down  from 
the  abdomen  into  the  scrotum,  it  will  be  found  that  it 
cannot  be  done,  owing  to  the  shortness  of  the  mesentery. 
In  any  case  of  scrotal  hernia,  therefore,  the  mesentery 
must  become  lengthened,  and  it  is  a  question  whether 
or  not  an  abnormally  long  mesentery  may  exist  as  a 
congenital  defect,  and  so  predispose  the  patient  to  rup- 
ture. More  information  is  required  upon  the  subject 

The  inguinal  canal  in  the  female  is  much 
smaller  and  narrower,  although  a  trifle  longer,  than  it 


chap,  xvi.]  HERNIA.  311 

is  in  the  male.  It.  is  occupied  by  the  round  ligament, 
and  offers  such  slight  inducement  to  the  formation  of 
a  i-upture,  that  acquired  inguinal  hernia  is  as  rare 
among  females  as  it  is  common  among  men.  In  the 
female  foetus  a  process  of  peritoneum  descends  for  a 
little  way  along  the  round  ligament.  It  corresponds 
to  the  processus  vaginalis  of  males,  and  is  known  as 
the  canal  of  Nuck.  If  this  process  remains  patent, 
as  it  not  infrequently  does,  it  may  lead  to  a  rupture  that 
corresponds  to  the  congenital  hernia  of  males.  Indeed, 
in  quite  early  life  the  inguinal  rupture  is  about  the  only 
form  met  with  in  female  children,  if  exception  be  made 
of  umbilical  hernia.  In  all  such  instances  of  early 
inguinal  hernia  the  gut  has  travelled  down  a  patent 
canal  of  Nuck. 

It  only  remains  to  be  said,  that  in  endeavouring  to 
reduce  an  inguinal  hernia  by  taxis  the  thigh  should 
be  flexed  and  adducted,  for  in  that  position  the  ab- 
dominal parietes  that  bound  the  inguinal  canal  are 
the  most  relaxed.  This  position  of  the  thigh  affects 
the  inguinal  region  mainly  through  the  attachments 
of  the  fascia  lata  to  Pou  part's  ligament. 

In  herniotomy  an  incision  is  made  along  the 
middle  of  the  tumour  and  in  its  long  axis,  being 
so  arranged  that  its  centre  shall  correspond  to 
the  external  ring.  The  superficial  external  pudic 
artery  is  usually  divided  in  the  operation.  It  is  im- 
possible to  distinguish  the  various  layers  of  tissue  that 
cover  the  hernia,  the  only  one,  as  a  rule,  that  is  re- 
cognisable being  the  layer  from  the  cremaster.  In 
dividing  the  constriction  it  is  usually  recommended  to 
cut  upwards  in  all  forms  of  inguinal  hernia.  The  only 
vessel  in  risk  of  being  damaged  is  the  deep  epigastric. 
In  the  oblique  form  of  rupture  an  incision  directly 
upwards  would  quite  avoid  this  artery  ;  but  in  a  direct 
hernia,  where  there  is  reason  to  suppose  that  the  vessel 
is  in  close  connection  with  the  neck  of  the  sac,  it  is 


312  SURGICAL  A  r  PLIED  ANATOMY.   [Chap.  xvi. 

well  that  the  incision  be  directed  a  little  inwards  as 
well  as  upwards.  It  should  be  remembered  that  the 
incision  required  to  relieve  a  constriction  is,  if  pro- 
perly applied,  of  the  most  insignificant  character. 

Femoral  hernia.— In  this  form  of  rupture  jbhe 
gut  leaves  the  abdomen  through  the  femoral  ring  and 
passes  down  into  the  thigh  along  the  crural  canal. 
The  name  "  crural  canal "  is  given  to  the  narrow 
interval  between  the  femoral  vein  and  the  inner  wall 
of  the  crural  sheath.  Like  the  inguinal  canal,  it  is 
a  potential  rather  than  an  actual  canal,  and  exists 
only  when  the  sheath  has  been  separated  from  the 
vein  by  dissection  or  by  a  hernial  protrusion  of  some 
kind.  The  canal  is  funnel-shaped,  about  half  an  inch 
in  length,  and  ends  opposite  the  saphenous  opening. 
Femoral  hernise  are  always  acquired,  and  possess  a  sac, 
made  by  themselves  out  of  the  parietal  peritoneum 
covering  the  crural  ring  and  its  vicinity.  The  canal 
is  larger  in  women  than  in  men,  and  thus  it  happens 
that  this  species  of  rupture  is  much  more  common  in 
the  former  sex.  The  tendency  to  this  hernia  in 
women  appears  also  to  be  increased  by  the  weakening 
effects  of  pregnancy  upon  the  abdominal  walls.  As 
the  gut  descends  it  pushes  in  front  of  it  its  sac  of 
peritoneum  and  the  septum  crurale  (the  name  given 
to  the  subserous  tissue  that  covers  in  the  femoral  ring) 
and  enters  the  crural  sheath.  The  adhesions  of  the 
sheath  limit  its  downward  progress  when  it  has 
travelled  about  half  an  inch,  and  it  therefore  passes 
forwards  through  the  saphenous  opening,  pushing 
before  it  the  cribriform  fascia.  It  then  receives  a 
covering  from  the  superficial  fascia  and  the  skin. 
Owing  to  the  rigidity  of  the  structures  about  the 
femoral  ring,  the  neck  of  the  sac  must  always  be 
small.  For  similar  reasons  its  dimensions  while  in 
the  femoral  canal  must  of  necessity  be  insignificant, 
but  when  once  it  has  escaped  through  the  saphenous 


Chap  xvi.]  HERNIA.  313 

opening  the  loose  subcutaneous  fasciae  of  the  groin 
afford  it  ample  opportunities  for  increase.  When  the 
hernia  has  passed  through  the  saphenous  opening  it 
tends  to  mount  upwards  over  Poupart's  ligament,  in 
the  direction  of  the  anterior  superior  iliac  spine.  Even 
when  it  overlaps  the  ligament  considerably  it  can 
hardly  be  mistaken  for  an  inguinal  hernia,  since  it 
must  always  lie  to  the  outer  side  of  the  pubic  spine. 
The  upward  tendency  of  a  femoral  hernia  has  been 
.variously  explained.  It  has  been  ascribed  to  a 
supposed  curve  in  the  crural  canal,  the  concavity  of 
which  is  forwards.  Scarpa  believed  it  to  receive  its 
direction  from  the  frequent  flexion  of  the  thigh. 
Probably  one  of  the  most  important  factors  in  the 
matter  is  the  unyielding  character  of  the  lower  edge 
of  the  saphenous  opening.  This  edge  tends  to  direct 
the  gut  forwards,  while  the  traction  upon  the 
mesentery,  that  is  inevitable  as  the  rupture  proceeds, 
may  be  conceived  as  favouring  an  upward  direction. 
The  coverings  of  a  hernia  that  has  found  its  way 
beneath  the  skin  are  often  very  scanty. 

Relations. — When  a  hernia  occupies  the  crural 
canal  there  are  in  front  of  it  the  skin  and  super- 
ficial fasciae,  the  iliac  part  of  the  fascia  lata,  the 
crural  arches,  the  cribriform  fascia,  and  the  anterior 
wall  of  the  crural  sheath.  Behind  are  the  pos- 
terior wall  of  the  crural  sheath,  the  pubic  portion 
of  the  fascia  lata,  the  pectineus  muscle,  and  the  bone. 
The  boundaries  of  the  femoral  ring  are,  in  front, 
Poupart's  ligament  and  the  deep  crural  arch  ;  behind, 
the  bone  covered  by  the  fascia  lata  and  the  pectineus  ; 
on  the  inner  side,  the  conjoined  tendon,  Gimbernat's 
ligament,  and  the  inner  part  of  the  deep  crural  arch ; 
on  the  outer  side,  the  femoral  vein  in  its  sheath.  The 
spermatic  cord  lies  (in  the  male)  just  above  the  anterior 
border  of  the  ring,  and  the  epigastric  artery  skirts  its 
upper  anrl  outer  part.  The  little  pubic  branch  of  this 


314  SURGICAL  APPLIED  ANATOMY.   [Chap.  xvi. 

artery  passes  round  the  ring  to  ramify  over  Gimbernat's 
ligament.  In  one  case  out  of  three  and  a  half  the 
obturator  artery  arises  from  the  epigastric.  Out 
of  one  hundred  and  one  cases  where  the  vessel  so 
arose  it  reached  its  destination  in  fifty-four  instances 
by  passing  along  the  outer  side  of  the  crural  ring, 
a  position  quite  free  from  danger  in  herniotoniy. 
In  thirty-seven  cases  it  passed  backwards  across  the 
ring,  and  in  ten  instances  round  its  inner  border 
(R.  Quain).  When  in  the  last-named  position  the 
vessel  could  hardly  escape  being  wounded  in  the 
operation  upon  a  femoral  hernia.  Indeed,  several 
cases  have  been  recorded  of  fatal  haemorrhage  from 
this  abnormal  vessel  in  such  operations.  In  one 
instance  the  pulsations  of  the  abnormal  artery  were 
felt  before  the  parts  wei-e  divided.  In  addition  to  the 
vessels  about  the  ring  there  is  also  a  pubic  vein, 
which,  ascending  from  the  obturator  vein  in  the 
thyroid  foramen,  enters  the  external  iliac  vein.  Its 
relation  to  the  crural  ring  varies  in  the  same  way 
as  the  abnormal  artery  last  named. 

The  size  of  the  femoral  canal  and  the  degree  of 
tension  of  its  orifices  varies  greatly  with  the  position 
of  the  limb.  If  the  thigh  be  extended,  abducted,  and 
rotated  outwards,  these  parts  are  made  very  tense, 
while  they  are  the  most  lax  when  the  limb  is  flexed, 
adducted,  and  rotated  inwards.  It  is  consequently 
in  the  latter  position  that  the  thigh  should  be  placed 
when  the  taxis  is  being  attempted.  In  herniotoniy 
the  incision  is  made  along  the  inner  side  of  the 
tumour,  and  is  so  arranged  that  its  centre  corresponds 
to  about  the  upper  part  of  the  saphenous  opening. 
The  constriction  is  usually  at  the  neck  of  the  sac,  and 
caused  by  Gimbernat's  ligament.  It  is  divided  by  an 
incision  directed  upwards  and  inwards. 

Obturator  hernia.— In  this  form  the  gut,  push- 
ing before  it  a  sac  of  peritoneum,  escapes  through  the 


chap,  xvi.]  HERNIA.  315 

obturator  canal  between  the  horizontal  ramus  of  the 
pubes  and  the  uppermost  fibres  of  the  obturator  ex- 
ternus  muscle.  The  obturator  vessels  may  be  either 
found  on  the  outer  or  inner  side  of  the  sac,  or  above  or 
behind  it.  In  a  series  of  cases  collected  by  Dr.  Firth 
the  vessels  were  to  the  inner  side  in  six  cases,  to  the 
outer  side  in  six  cases,  and  behind  in  three  cases. 
The  proximity  of  the  nerve  renders  it  very  liable  to 
be  pressed  upon,  and  pain  along  the  nerve  is  often  a 
marked  feature  of  the  rupture.  The  hernia  presents 
beneath  the  pectineus  muscle,  to  the  inner  side  of  the 
capsule  of  the  hip,  behind  and  to  the  inner  side  of  the 
femoral  vessels,  and  to  the  outer  side  of  the  adductor 
longus  tendon.  Pain  on  moving  the  hip  is  generally 
a  conspicuous  symptom.  This  hernia  is  more  common 
in  females  ;  and  it  is  worthy  of  note  that  the  orifice  of 
the  obturator  canal  can  be  examined,  to  some  extent, 
through  the  vagina.  Professor  Wood  reports  a  re- 
markable case  where  a  hernial  protrusion  of  a  part  of 
the  adductor  longus  through  a  rent  in  its  aponeurosis 
was  mistaken  for  an  obturator  hernia. 

Rare  (onus  of  hernia. — In  perineal  hernia 
the  sac,  covered  by  the  recto-vesical  fascia,  escapes 
through  the  anterior  fibres  of  the  levator  ani  muscle, 
between  the  prostate  (or  vagina)  and  the  rectum. 
In  jmdendal  hernia  the  sac  lies  in  the  posterior  inferior 
half  of  the  labium  pudendi,  escaping  between  the 
ascending  ramus  of  the.  ischium  and  the  vagina.  In 
sciatic  hernia  the  gut  escapes  through  the  sciatic 
notch  in  front  of  the  internal  iliac  vessels,  above  or 
below  the  pyriformis,  and  appears  under  the  gluteus 
maximus  muscle.  As  regards  umbilical  hernia, 
nothing  remains  to  be  added  to  what  has  been  already 
said  (page  294),  save  that  the  sac  from  its  position 
nearly  always  contains  omentum,  and  may  contain 
stomach.  In  lumbar  /ternia  the  gut  escapes  in  front 
of  the  ijuadratus  lumborum  muscle,  and  appears  on  the 


316  SURGICAL  APPLIED  ANATOMY.   [Chap.  xvi. 

sui-face  through  the  triangle  of  Petit  (the  gap  between 
the  latissimus  dorsi  and  external  oblique  muscles),  and 
therefore  just  above  the  highest  point  of  the  iliac 
crest.  The  sac  must  either  force  before  it,  or  (in  cases 
of  injury)  come  through  the  fascia  lumborum  and 
internal  oblique  muscles,  since  those  structures  form  the 
floor  of  the  triangle.  Macready  (Lancet,  Nov.  8th, 
1890)  has  collected  twenty -five  examples  of  this  hernia. 
Diaphragmatic  hernice  may  be  congenital  or  acquired. 
The  former  variety  is  by  far  the  more  common,  and  is 
due  to  simple  arrest  in  the  development  of  the  dia- 
phragm and  persistence  of  the  original  connection 
between  the  thorax  and  abdomen.  The  acquired  form 
usually  follows  a  laceration  of  the  diaphragm  from 
injury.  In  any  case  some  of  the  abdominal  viscera  are 
protruded,  through  the  gap  in  the  midriff,  into  the 
thoracic  cavity.  Owing  to  the  presence  of  the  liver  on 
the  right  side,  these  hernise  are  much  more  common 
on  the  left  side.  Of  the  organs,  the  stomach  is  the 
most  frequently  dislodged,  then  the  transverse  colon, 
omentum,  small  gut,  spleen,  liver,  pancreas,  and 
kidneys  in  the  order  named  (Leichtenstern).  The 
hernia  may  escape  through  the  foramen  for  the  gullet, 
but  never  through  that  for  the  vena  cava,  nor  through 
the  hiatus  aorticus.  The  parts  commonly  selected  are 
the  connective  tissue  intervals  between  the  sternal  and 
costal  origins  of  the  diaphragm  in  front  and  its  verte- 
bral and  costal  origins  behind.  These  hernia?  are 
more  common  in  males. 

Posterior  abdominal  parictes.— The  lateral 
and  posterior  walls  of  the  abdomen  are  lined  inside  with 
two  fasciae,  the  transversalis  and  iliac.  The  transversalis 
fascia  lines  the  whole  of  the  transversalis  muscle,  and  is 
much  thicker  below  than  above.  Above  it  joins  the 
fascia  covering  the  diaphragm,  while  below  it  is  at- 
tached to  the  iliac  crest,  and  to  the  whole  of  Poupart's 
ligament,  save  at  that  spot  where  it  passes  into  the 


chap,  xvi.]  POSTERIOR  ABDOMINAL  PARIETES.      317 

thigh  to  form  the  anterior  layer  of  the  crural  sheath. 
The  iliac  fascia  encloses  the  ilio-psoas  muscle,  the  part 
over  the  psoas  being  the  thinner.  This  part  is  attached 
on  the  inner  side  to  the  sacrum,  and  to  the  spine  at 
points  corresponding  to  the  psoas  origin.  Above,  it  is 
attached  to  the  ligamentum  arcuatuni  internum,  and 
on  the  outer  side  to  the  anterior  layer  of  the  lumbar 
fascia  along  the  outer  edge  of  the  psoas.  Below,  the 
fascia  encloses  the  iliacus,  and  is  attached  to  the  iliac 
crest,  to  the  pelvic  brim,  and  to  Poupart's  ligament, 
save  at  that  part  where  the  membrane  passes  beneath 
the  ligament  to  form  the  posterior  wall  of  the  crural 
sheath.  It  follows  the  ilio-psoas  muscle  to  its  insertion, 
and  ends  by  blending  with  the  fascia  lata. 

The  arrangement  of  these  fasciae  greatly  influences 
the  progress  and  direction  of  abscess.  Thus  an  abscess 
beneath  the  transversalis  fascia  will  be  very  definitely 
enclosed.  If  it  progresses  backwards  it  will  be  stopped 
at  the .  outer  edge  of  the  psoas  muscle.  If  it  spreads 
downwards  it  will  be  arrested  by  the  attachments  of 
the  fascia  to  the  iliac  crest  and  to  Poupart's  ligament, 
and  will  be  unable  to  spread  (unless  the  fascia  be 
pierced)  into  either  the  pelvis  or  the  thigh.  On  the 
inner  side  it  will  be  checked  at  the  middle  line ;  and 
above,  although  it  will  meet  with  no  actual  resist- 
ance, it  would  be  indisposed  to  spread,  since  its  move- 
ments would  be  against  gravity.  Thus,  it  happens 
that  collections  so  placed  point  either  just  above  the 
iliac  crest  or  Poupart's  ligament,  or  run  down  along  the 
spermatic  cord,  and  distend  the  inguinal  canal. 

The  iliac  fascia  encloses  the  ilio-psoas  in  a  very 
distinct  osseo-aponeurotic  space.  Between  the  fascia 
and  the  muscle  (especially  its  iliac  division)  there  is 
a  good  deal  of  loose  connective  tissue,  and  thus  every 
facility  is  offered  for  the  progress  of  subfascial  abscesses 
in  this  region.  The  osseo-aponeurotic  space  is  practi- 
cally closed  on  all  sides  within  the  abdomen,  and  is 


318  SURGICAL  APPLIED  ANATOMY.   [Chap.  xvi. 

only  open  below  where  the  fascia  passes  with  its 
muscle  into  the  thigh.  This  opening  being  at  the 
most  dependent  part  of  the  space,  it  follows  that  the 
psoas  or  iliac  abscess  very  commonly  points  on  the 
upper  part  of  the  thigh,  just  to  the  outer  side  of  the 
femoral  vessels.  An  abscess  in  the  iliac  fossa,  although 
most  likely  to  reach  the  thigh,  might  mount  up  to  the 
superior  attachments  of  the  fascia,  and  point  at  the  iliac 
crest,  or  at  the  outer  part  of  Poupart's  ligament.  Or  it 
may  disregard  the  inner  attachments  of  the  fascia  and 
gravitate  into  the  pelvis.  If  the  patient  should  occupy 
for  long  the  recumbent  posture,  there  is  no  reason  why 
it  should  not  extend  upwards  along  the  psoas  muscle. 

The  term  iliac  abscess,  however,  is  often  applied  to 
collections  that  are  not  within  the  space  formed  by  the 
iliac  fascia,  but  that  are  situated  rather  in  the  subserotis 
connective  tissue.  This  tissue  is  very  extensive  in  the 
iliac  fossae,  and  favours  the  formation  of  large  purulent 
collections.  Kcenig's  experiments  of  injecting  fluid 
into  this  subserous  space  show  that  an  abscess  so 
placed  may  spread  in  any  direction  by  simply  dissect- 
ing off  the  peritoneum.  Clinically,  however,  such  col- 
lections are  greatly  limited  by  gravity.  They  are  apt  to 
remain  in  the  iliac  fossa,  bulging  out  the  abdominal 
wall  just  above  Poupart's  ligament,  and  occupying  the 
angle  formed  by  the  union  of  the  iliac  and  transver- 
salis  fasciae.  In  some  cases  they  are  disposed  to 
extend  into  the  pelvis. 

The  abscess,  when  in  the  subserous  tissue,  is 
brought  in  close  contact  with  certain  of  the  viscera, 
especially  with  the  caecum  and  sigmoid  flexure,  and 
into  these  portions  of  the  colon  it  may  open.  Thus,  I 
have  seen  a  case  of  iliac  abscess,  due  to  pelvic  necrosis, 
that  opened  into  the  sigmoid  flexure,  and  at  the  same 
time  discharged  through  sinuses  about  the  eroin.  Jn 

^  * 

this  case  some  pus  passed  by  the  anus,  while  on  the 
other  hand  some  faecal  matter  escaped  by  the  groin. 


Chap.  XVI.]  PSOAS   ABSCESS.  319 

Retro-peritoneal  abscesses  in  the  pelvis  (pelvic  cellu- 
litis)  may  mount  up  into  the  iliac  fossae,  may  appear 
as  "iliac  abscesses,"  and  may  ultimately  discharge 
themselves  by  many  openings  in  the  lower  parts  of 
the  anterior  abdominal  wall. 

It  may  be  well  to  note  that  the  common  and 
external  iliac  vessels,  the  lymphatics  and  the  ureters, 
are  outside  the  iliac  fascia,  and  rest  upon  its  abdo- 
minal surface,  while  the  anterior  crural  nerves  and 
abdominal  parts  of  the  lumbar  nerves  are  within 
the  osseo-aponeurotic  space.  Thus,  the  suprafascial 
abscess  may,  with  little  difficulty,  reach  the  thigh  by 
following  the  iliac  vessels ;  while  the  subfascial 
collection  would  pursue  the  anterior  crural  nerve. 

A  psoas  abscess,  or  abscess  within  the  fascial 
sheath  of  the  psoas  muscle,  is  usually  due  to  spinal 
caries,  although  it  may  appear  independently  of  that 
disease.  If  the  lumbar  spine  be  involved,  the  matter 
can  pass  directly  into  the  substance  of  the  muscle, 
which  it  will  more  or  less  entirely  destroy.  If  the  mis- 
chief be  in  the  dorsal  spine,  the  matter  gravitates  along 
the  front  of  the  column  until  it  reaches  the  diaphragm, 
which  it  pierces  by  an  inflammatory  process.  It  is 
now  brought  into  relation  with  the  heads  of  the  psoas, 
and  has  to  pass  through  a  narrow  strait.  "It  is 
prevented  from  enlarging  on  the  fore-part  by  the  liga- 
menta  arcuata,  and  at  the  back  by  the  spine  and  lowest 
rib  ;  hence,  in  order  to  proceed  it  has  to  force  its  way 
in  the  line  of  the  psoas  muscle.  That,  however,  can 
only  be  done  by  peneti'ating  into  its  interior.  It  ac- 
complishes this,  in  the  first  place,  by  inserting  its  most 
advanced  part,  like  a  wedge,  between  the  two  origins 
(viz.  from  the  bodies  of  the  vertebrae,  and  from  the 
corresponding  transverse  processes) :  it  then  splits  and 
distends  the  fibres,  so  as  to  form  a  cavity  for  the 
reception  of  the  pus  ....  and  the  psoas  at  length  is 
converted  more  or  less  thoroughly  into  an  abscess" 


320  SURGICAL  APPLIED  ANATOMY.   [Chap.  xvi. 

(Shaw).  The  pus,  following  the  muscle,  at  last  reaches 
the  thigh,  and  usually  points,  just  below  the  groin,  to 
the  outer  side  of  the  femoral  vessels. 

The  abscess,  however,  often  shows  much  variation. 
It  may  avoid  the  psoas,  or  leave  it  when  once  it  has 
entered  it,  and  make  its  way  into  the  lumbar  region, 
to  find  an  exit  in  the  loin.  Or  it  may  extend  into  the 
iliac  fossae,  and  open  above  the  groin,  or  mount  up  over 
the  iliac  crest,  and  discharge  in  the  gluteal  region. 
It  may  pass  along  the  inguinal  canal,  and  be  mis- 
taken for-  a  hernia.  It  may  sink  into  the  pelvis,  and 
may  open  into  the  bladder,  or  discharge  itself  through 
the  great  sciatic  foramen,  or  through  a  sinus  in  the 
perineum.  Some  of  the  latter  cases  have  led  to  much 
confusion  in  diagnosis,  since  there  would  appear  to  be 
little  connection  between  caries  of  the  spine  and  a 
perineal  abscess. 

Lumbar  region.— The  muscles  that  form  the 
lateral  and  posterior  walls  of  the  abdomen,-  and  that  fill 
in  the  interval  between  the  iliac  crest  and  the  lowest 
rib,  are  the  external  oblique  and  latissimus  dorsi, 
the  internal  oblique,  the  transversalis  muscle  and 
fascia  lumborum,  the  erector  spime  and  quadratus 
lurnborurn. 

The  external  oblique  and  latissimus  dorsi  muscles 
are  separated  by  a  small  triangular  interval  below  (the 
triangle  of  Petit),  but  above  they  overlap.  The  interval 
between  these  two  muscles  may  be  represented  by  a 
line  drawn  vertically,  upwards  from  the  middle  of  the 
crest  of  the  ilium.  The  outer  edge  of  the  quadratus 
lumborum  corresponds  to  this  line,  just  above  the  iliac 
crest ;  but  as  the  border  of  the  muscle  slopes  upwards 
and  backwards,  it  may  be  about  an  inch  behind  the 
line,  at  a  point  midway  between  the  crest  and  the  last 
rib.  The  edge  of  the  muscle  is  overlapped  by  the 
internal  oblique,  and  its  inner  half  or  two-thirds  is 
overlapped  by  the  erector  spiuae.  The  subcutaneous 


Chap,  xvi.]  LUMBAR  REGION.  321 

tissue  in  the  lumbar  region  is  very  extensive,  and  is  a 
favourite  locality  for  chronic  abscess.  The  looseness 
and  extent  of  tue  tissue  also  permit  of  large  extrava- 
sations of  blood.  It  is  in  the  muscles  and  fascia 
along  the  spine  in  this  region  that  the  rheumatic 
affection  known  as  lumbago  has  its  seat. 

Between  the  last  rib  and  the  iliac  crest  is  stretched 
the  dense  fascia  lumborum,  the  posterior  aponeurosis 
of  the  transversalis  muscle.  It  is  pierced  near  the  rib 
by  the  last  intercostal  artery  and  nerve  and  near  the 
ilium  by  the  ilio-hypogastric  nerve  and  its  accompany- 
ing artery.  It  is  along  these  structures  that  an  abscess 
may  possibly  find  its  way  through  the  fascia  in  certain 
cases.  The  fascia  divides  behind  into  three  layers,  to 
enclose  in  definite  spaces  the  quadratus  and  erector 
epinse  muscles.  Within  these  spaces  or  compartments 
suppuration  may  be  for  some  time  limited.  A  lumbar 
abscess  commencing  in  some  adjacent  part,  as  in  the 
spine  or  in  the  loose  tissue  around  the  kidneys, 
usually  spreads  backwards  by  piercing  the  fascia 
lumborum  or  the  quadratus  muscle.  It  then  finds  its 
way  through  the  internal  oblique,  and  appears  on  the 
surface  between  the  external  oblique  and  latissimus 
dorsi  muscles,  and  at  the  outer  border  of  the  erector 
spinae.  It  should  be  noted  that  the  quadratus  muscle 
is  very  thin,  and  offers  little  resistance  to  protrusions 
from  within,  while  a  great  part  of  the  muscle  is  firmly 
supported  behind  by  the  erector  spinae. 

The  author's  operation  for  caries  of  the 
lumbar  vertebrae. — The  lumbar  vertebrae,  and, 
possibly,  the  last  dorsal,  may  be  reached  by  an  incision 
through  the  loin.  A  vertical  cut  is  made  along  the 
outer  edge  of  the  erector  spinse  muscle.  The  fibres  of 
that  muscle  having  been  drawn  aside,  the  middle 
layer  of  the  fascia  lumborum  is  incised,  and  the  quad- 
rated lumborum  is  exposed.  This  muscle  is  divided 
vertically,  and  then  the  front  of  the  vertebra  may  be 
v— 4 


322  SURGICAL  APPLIED  ANATOMY,  rchap  xvn. 

reached  by  introducing  the  finger  under  the  psoas 
muscle.  Through  this  incision  the  author  has  removed 
the  whole  of  the  body  of  the  first  lumbar  vertebra 
that  had  been  separated  as  a  sequestrum.*  The 
lumbar  arteries  are  avoided  by  keeping  close  to  the 
transverse  process  of  the  vertebrae.  Through  this 
incision  a  psoas  abscess  may  be  most  conveniently 
opened. 


CHAPTER  XVII. 

THE     ABDOMINAL     VISCERA. 

THE  peritoneum. — Certain  of  the  viscera,  as, 
for  example,  the  stomach,  spleen,  and  small  intestines, 
are  so  closely  invested  with  peritoneum  that  they  could 
not  be  wounded  without  that  membrane  being  wounded 
also.  Inflammatory  affections  of  such  viscera  are  also 
very  apt  to  involve  the  peritoneum.  Other  organs, 
such  as  the  kidney,  descending  colon,  pancreas,  etc., 
are  so  imperfectly  covered  with  the  serous  membrane 
that  a  wound  of  those  organs  need  not  involve  it, 
nor  need  it  be  implicated  in  even  extensive  inflam- 
matory changes.  Large  abscesses  may,  for  instance, 
form  about  the  kidney  and  discharge  themselves 
through  the  skin  without  any  peritonitis  being 
induced.  Spontaneous  perforation,  of  the  small  intes- 
tine must  involve  the  peritoneum,  while,  on  the 
other  hand,  the  caecum  and  descending  colon  may 
become  perforated,  and  the  matter  escape  into  the 
subserous  tissue  without  the  serous  membrane  being 
in  any  way  involved.  It  is  a  strange  fact  that  it  is 
singularly  easy  to  set  up  inflammation  of  the  perito- 
neum if  the  membrane  be  approached  from  its 
inner  surface,  but  comparatively  difficult  if  it  be  ap- 
proached from  without.  Thus  a  small  puncture  of  the 
*Med.-Chir.  Trans.,  1884. 


Chap,  xvn.}          ABDOMINAL   VISCERA.  323 

membrane  may,  on  the  one  hand,  lead  to  fatal  peri- 
tonitis, while,  on  the  other,  it  may  be  extensively 
torn  from  its  attachments  (as  in  ligaturing  the  common 
iliac  artery  from  the  side)  without  any  peritonitis 
following.  Or,  again,  a  little  pus  escaping  on  the 
inner  surface  of  the  membrane  may  lead  to  inflam- 
mation, while  the  outer  surface  may  be  bathed 
with  pus  for  a  long  while  (as  in  large  perirenal 
abscesses)  without  any  peritonitis  being  produced. 
Inflammation  of  the  peritoneum  may  lead  to  the 
formation  of  a  great  variety  of  bands  and  adhesions, 
beneath  which  pieces  of  intestine  may  be  caught  and 
strangulated. 

The  peritoneum  will  allow  of  very  considerable 
stretching  if  only  that  stretching  be  effected  gradu- 
ally. This  is  frequently  seen  in  cases  of  gradual  dis- 
tension of  the  bowel,  and  in  the  formation  of  the  sac 
in  hernia.  Abrupt  stretching  of  the  membrane 
leads  to  certain  rupture  of  it.  The  parietal  peri- 
toneum may  be  ruptured  by  violence  without  damage 
to  any  of  the  viscera. 

The  great  oineiituin  is,  from  its  position, 
very  apt  to  be  wounded.  In  small  wounds  of 
the  front  of  the  belly  it  very  often  protrudes 
and  acts  as  an  excellent  plug  to  prevent  the 
escape  of  other  and  more  important  structures. 
It  is  often  found  in  hernia,  especially  in  umbilical 
hernia,  where  it  is  almost  constant.  Its  limits 
vary,  and  it  has  an  inclination  to  the  left  side.  This 
depends  upon  the  fact  that  the  omentum  is  developed 
from  the  meso-gaster,  and  accounts  for  the  fact  that 
hernias  containing  omentum  are  much  more  common 
on  the  left  side.  The  omentum,  like  other  parts  of 
the  peritoneum,  is  apt  to  inflame,  and  to  contract 
adhesions  to  the  neighbouring  parts.  These  adhesions 
are  often  of  the  greatest  service  in  limiting  inflam- 
matory and  hsemorrhagic  extravasations,  by  matting 


324  SURGICAL  APPLIED  ANATOMY.  rChap.xvn. 

the  bowels  together  and  forming  spaces  between  them. 
In  perforation  of  the  bowel  from  disease,  an  opportune 
adhesion  of  the  omentum  over  the  aperture  may 
prevent  escape  of  the  intestinal  contents. 

Large  masses  of  tissue  may  be  nourished  through 
an  adherent  omentum.  Thus  when  the  proper  blood 
supply  of  an  ovarian  tumour  has  been  cut  off  by 
twisting  of  its  pedicle,  the  growth  may  be  nourished 
through  the  omentum,  if  that  structure  is  adherent  to 
it.  In  hernise  the  omentum  generally  contracts  adhe- 
sions to  the  sac,  and  becomes  irreducible,  or  it  may 
form  a  kind  of  second  sac  about  the  gut  itself  ("omen- 
tal  sac ").  The  end  of  the  omentum,  by  becoming 
adherent  to  distant  parts,  as  to  the  pelvic  viscera,  may 
form  itself  into  a  firmly  attached  band,  beneath  which 
the  bowel  may  be  fatally  strangled.  In  like  manner 
the  intestine  has  been  strangulated  through  slits  and 
holes  that  have  developed  in  the  omentum,  usually  as 
a  result  of  inflammatory  adhesions.  When  the  great 
omentum  contains  much  fat  it  must  act  as  an  excellent 
protection  to  the  bowels,  and  must,  as  a  layer  of  non- 
conducting material,  help  to  maintain  the  equality  of 
their  temperature. 

The  mesentery. — The  parietal  attachment  of  the 
mesentery  is  liable  to  some  variation.  The  point  at 
which  this  attachment  commences  above  is  practically 
constant.  It  corresponds  with  the  ending  of  the  duo- 
denum, is  about  on  a  level  with  the  lower  border  of  the 
pancreas,  and  is  just  to  the  left  of  the  second  lumbar 
vertebra.  (See  page  338.)  From  this  point  the 
insertion  of  the  mesentery  follows  an  oblique  line  that 
runs  downwards  and  to  the  right,  crossing  the  great 
vessels,  and  then  ending  in  a  somewhat  uncertain 
manner  on  the  right  iliac  fossa.  Its  right  or  upper 
layer  is  continuous  with  the  under  layer  of  the  trans- 
verse meso-colon,  and  with  the  peritoneum  that  invests 
the  ascending  colon.  Its  left  or  lower  layer  joins  with 


Chap. xvn.]          ABDOMINAL   VISCERA.  325 

the  serous  membrane  that  encloses  the  descending 
colon,  that  forms  the  sigmoid  mesentery,  and  that 
descends  over  the  lumbo-sacral  eminence  into  the 
pelvis.  The  parietal  attachment  of  the  mesentery 
measures,  as  a  rule,  about  sij  in.cjj.es.  From  its  oblique 
attachment  it  follows  that,  when  haemorrhage  takes 
place  in  the  abdomen  on  the  right  side  of  the 
mesentery,  the  blood  first  is  conducted  into  the  right 
iliac  fossa,  when  on  the  left  side,  into  the  pelvis. 
This  may  explain  the  circumstance  that  collections  of 
blood  are  more  common  in  the  right  than  in  the  left 
iliac  fossa. 

The  length  of  the  mesentery  from  the  spine  to  the 
bowel  varies  in  different  parts  of  the  canal ;  its 
average  length  is  eight  inches.  The  longest  part  is 
that  which  goes  to  "the  coils  of  intestine  that  lie 
between  a  point  six  feet  from  the  duodenum,  and  a 
point  eleven  feet  from  the  same  part  of  the  gut 
(Author).*  Such  coils  will,  therefore,  include  five  feet 
of  the  intestine,  and  the  mesentery  here  may  reach 
the  length  of  ten  inches.  These  coils  are  apt  to  hang 
in  the  pelvis,  and  may  be  easily  herniated.  The 
length  of  the  mesentery  plays  an  important  part 
in  hernia.  If  the  fresh  body  of  an  adult  be  opened, 
and  the  condition  of  the  viscera  and  peritoneum  be 
normal,  it  will  be  fcmnd  that  it  is  impossible  to  drag 
a  loop  of  small  intestine  through  the  femoral  canal 
(artificially  enlarged)  on  to  the  thigh,  or  down  the 
inguinal  canal  into  the  scrotum.  In  fact,  no  coil  can, 
in  any  part,  be  drawn  out  of  the  abdomen  below  a 
horizontal  line  on  a  level  with  the  spine  of  the  pubes. 
It  is  evident,  therefore,  that  in  femoral  or  scrotal 
hernia  the  mesentery  must  be  elongated  or  its  attach- 
ments lowered. 

The  mesentery  is  relatively  longest  in  infancy  and 

*  See  "  The  Anatomy  of  the  Intestinal  Canal  and  Peritoneum 
In  Man,"  by  the  Author.  London,  1885. 


326  SURGICAL  APPLIED  ANATOMY.  [Chap. xvn. 

childhood,  and  a  freer  escape  of  the  intestines  from 
the  abdomen  is  allowed  in  subjects  under  puberty. 
The  disposition  of  the  membrane  permits  also  a  freer 
downward  excursion  of  the  bowels  on  the  right  side, 
and  this  has  been  offered  as  an  explanation  of  the 
undue  frequency  of  right-sided  inguinal  hernise  in 
childhood  (Lockwood). 

The  root  of  the  mesentery,  and,  indeed,  the  whole 
of  the  peritoneum  covering  the  posterior  abdominal 
wall,  may  glide  a  little  downwards  and  constitute  a 
"  prolapse  of  the  mesentery."  This  condition  has  been 
fully  investigated  by  Mr.  Lockwood,  who  states  that 
it  seldom  occurs  before  middle  age,  that  it  causes  the 
mass  of  the  intestines  to  incline  to  the  left  and  thus  en- 
courages double  and  left-sided  hernia?.  These  hernia? 
are  well  known  to  be  more  common  after  middle  age. 

Mr.  Lockwood  states  that  in  acquired  hernia  the 
mesentery  is  found  to  have  had  its  attachments 
lowered  rather  than  to  have  been  increased  in  length. 

Certain  holes  are  sometimes  found  in  the  mesen- 
tery, through  which  intestine  has  been  strangulated. 
Some  of  these  holes,  especially  those  that  are  slit-like, 
are  due  to  injury,  others  are  due  to  congenital  defect 
of  the  mesentery.  I  have  shown  that  the  latter  holes 
are  round,  are  in  the  mesentery  of  the  lower  ileum, 
and  occupy  an  oval  area,  circumscribed  by  an  anasto- 
motic  arch  between  the  ileo-colic  branch  of  the  superior 
mesenteric  artery  and  the  last  of  the  intestinal  arteries. 
This  area  is  often  the  seat  of  atrophied  peritoneum, 
and  shows  an  absence  of  fat,  of  visible  blood-vessels, 
and  of  glands.  It  would  be  easy  for  a  knuckle  of  gut 
to  be  forced  through  the  thinned  membrane,  which  is 
sometimes  already  cribriform. 

For  an  account  of  "mesenteric  hernia"  see 
page  339. 

Herm'se  have  nocurred  through  the  foramen  of 
Winslow. 


Chap,  xvii.]          ABDOMINAL   VISCERA.  327 

I  have  described   a   strangulated  hernia  in  this 
position  which  was  exposed  by  operation. 

THE  STOMACH. 

Above. 
Liver,  small  omentum,  diaphragm. 

Behind. 


In  front. 

(From    left    to    right) 

diaphragm,     abdominal 

wall,  liver. 


Stomach. 


Transverse  meso-colon, 
pancreas,  crura,  solar 
plexus,  great  vessels, 
spleen,  left  kidney,  and 
capsule. 


Below. 
Great  omentum,  transverse  colon,  gastro-splenic  omentum. 

When  empty,  the  stomach  lies  at  the  back  of  the 
abdomen,  beneath  the  liver  and  some  way  from  the 
surface.  When  distended,  the  greater  curvature  is  ele- 
vated and  carried  forwards,  the  anterior  surface  is 
turned  upwards,  and  the  posterior  downwards  (Fig. 
34).  The  direction  of  the  rotation  depends  upon 
the  fixity  of  the  smaller  curvature.  When  dis- 
tended, the  stomach  is  brought  well  against  the 
anterior  belly  wall,  and  may  occupy  the  whole  of  the 
middle  line  as  far  as  the  navel.  Thus  the  stomach 
is  much  more  exposed  to  injury  when  full  than 
when  empty.  The  cardiac  orifice  is  situate  behind 
the  seventh  left  costal  cartilage,  about  one  inch  from 
the  sternum  (Fig.  30).  The  pylorus,  when  the  viscus 
is  empty,  lies  just  to  the  right  of  the  middle  line,  from 
two  to  three  inches  below  the  sterno-xiphoid  articula- 
tion on  the  level  of  a  line  drawn  between  the  bony  ends 
of  the  seventh  ribs.  When  the  stomach  is  distended 
the  pylorus  may  be  moved  nearly  three  inches  to 
the  right  (Braune).  The  cardiac  orifice  is  on  a  level 
behind  with  the  ninth  dorsal  spinous  process,  the 
pylorus  with  the  twelfth  dorsal  spine  (Fig.  31).  A 
horizontal  line  drawn  between  the  extreme  tips  of  the 
tenth  costal  cartilages  will  about  correspond  to  the 
lower  border  of  the  non-distended  stomach.  The 


328  SURGICAL  APPLIED  ANATOMV    [Chap,  xvn 


'ffig.  30.— Diagram  showing  the  Relations  of  the  Viscera  ro  the  Parietes 

(Anterior  view). 
8,  Stomach  ;  t,,  liver ;  K,  kidney ;  TC,  transverse  colon ;  o,  umbilicus. 


Chap  xvii.]          ABDOMINAL   VISCERA.  329 

tenth  cartilage  has  a  distinct  tip  and  plays  over  the 
cartilage  of  the  ninth  rib,  producing  under  the  finger 
a  special  crepitus.  Thefundus  of  the  stomach  reaches 
on  the  left  side  as  high  as  the  level  of  the  sixth  sterno- 
chondral  articulation,  being  a  little  above  and  behind 
the  heart  apex.  The  close  relations  of  the  stomach 
to  the  diaphragm  and  thoracic  viscera  serve  in  part  to 
explain  the  shortness  of  breath  and  possible  palpita- 
tion of  the  heart,  etc.,  that  may  follow  upon  distension 
of  the  organ  (Fig.  33).  The  near  proximity  of  the 
heart  to  the  stomach  is  illustrated  by  a  case  where  a 
thorn  (of  the  Pi'unus  spinosa),  half  an  inch  long,  had 
been  swallowed,  and  had  then  found  its  way  through 
the  diaphragm  and  pericardium  into  the  wall  and 
cavity  of  the  right  ventricle. 

On  reference  to  the  development  of  the  stomach,  it 
will  be  seen  that  it  is  originally  placed  vertically  in 
the  abdomen.  This  position  may  be  to  a  great  extent 
maintained  in  adult  life.  The  feats  of  an  acrobat  who 
styles  himself  "  the  sword  swallower  "  can  hardly  be 
explained  on  any  other  supposition  than  that  his 
stomach  is  vertical ;  but  whether  such  condition  is 
congenital,  or  has  been  produced  by  the  manoeuvre 
he  practises,  must  be  an  open  question. 

Although  the  mobility  of  the  stomach  is  not  con- 
siderable, yet  it  is  frequently  found  to  occupy  both 
diaphragmatic  and  epigastric  hernise. 

The  viscus  is  susceptible  of  enormous  dilatation 
when  the  pylorus  is  obstructed.  The  distended  organ 
may  reach  as  low  as  Poupart's  ligament. 

The  stomach  has  been  frequently  wounded.  In 
most  cases  a  fatal  result  rapidly  follows  upon  these 
injuries,  for  the  contents  of  the  stomach  escape 
into  the  peritoneal  cavity  and  set  up  an  acute  peri- 
tonitis. The  most  certainly  and  rapidly  fatal  cases, 
therefore,  are  those  in  which  the  stomach  was  full  of 
food  at  the  time  of  the  accident.  The  empty  stomach, 


33°  SURGICAL  APPLIED  ANATOMY.  [Chap.xvn. 

being  deeply  placed  and  lying  against  the  posterior 
abdominal  wall  in  a  collapsed  state,  is  but  little  ex- 
posed to  injury.  A  small  punctured  wound  of  the 
stomach  need  not  be  followed  by  escape  of  contents, 
since  the  loosely  attached  mucous  membrane  may 
escape  from  the  wound  and  effectually  plug  it.  The 
stomach  has  protruded  through  wounds  in  the  ab- 
dominal walls,  and  has  been  returned,  with  no  evil 
results  following.  In  a  few  cases  the  belly  wall  in 
front  of  the  stomach  has  been  wounded,  the  viscus  has 
protruded,  its  anterior  wall  has  been  wounded  by  the 
same  injury  that  penetrated  the  parietee,  and  a  fistu- 
lous  opening  leading  into  the  stomach  cavity  has 
resulted.  The  best  example  of  such  cases  is  afforded 
by  the  well-known  instance  of  Alexis  St.  Martin,  the 
subject  of  so  many  physiological  experiments.  In  this 
man  the  abdominal  parietes  in  front  of  the  stomach 
were  torn  away  by  a  gunshot  wound,  a  part  of  the 
anterior  wall  of  the  stomach  sloughed,  and  a  perma- 
nent fistula  resulted.  Dr.  Murchison.  reports  the  case 
of  a  woman  in  whom  a  gastric  fistula  was  produced  by 
the  continued  pressure  of  a  copper  coin  worn  over  the 
epigastric  region.  This  coin  was  deliberately  worn  by 
the  patient  in  order  to  excite  a  lesion  that  would 
arouse  the  sympathy  of  her  friends.  The  pressure  led 
to  an  ulceration  that  finally  opened  up  the  stomach. 
In  many  cases  the  fistula  has  been  due  to  ulcerative 
diseases  commencing  in  the  stomach  itself  and  spread- 
ing outwards. 

Some  remarkable  cases  have  been  recorded  where 
foreign  substances  have  been  swallowed  and  have 
lodged  in  the  stomach.  Certain  of  these  cases  serve 
to  illustrate  the  capacity  of  the  stomach,  and  among 
the  most  striking  is  an  instance  where  the  viscus  at 
death  was  found  to  contain  thirty-one  entire  spoon- 
handles,  each  about  five  inches  long,  four  half-handles, 
nine  nails,  half  an  iron  shoe-heel,  a  screw,  a  button, 


chap,  xvii.]          ABDOMINAL   VISCERA.  331 

and  four  pebbles.  The  -whole  mass  weighed  2  Ibs.  8  ozs. 
The  patient  was  a  lunatic.  The  pylorus  has  an  average 
diameter  of  16  mm.  This  about  corresponds  to  the 
diameter  of  a  sixpenny-piece.  In  spite  of  the  narrow- 
ness of  the  pylorus,  large  substances  that  have  been 
swallowed  have  been  passed  by  the  anus  without 
trouble.  Among  these  may  be  noted  a  metal  pencil- 
case  4|  inches  long,  ten  ounces  of  garden  nails  and 
fragments  of  crockery-ware  swallowed  by  a  lunatic  ;  a 
fork,  a  door-key,  and  other  strange  bodies.  Needles 
and  similar  sharp  substances  that  have  been  swallowed 
have  travelled  out  of  the  stomach  or  bowels  and  have 
found  their  way  to  the  surface  at  various  points  in  the 
body.  In  a  patient  under  my  care  at  the  London 
Hospital  I  extracted  from  beneath  the  skin,  near  the 
groin,  a  needle  swallowed  some  months  previously. 
In  a  case  reported  in  the  Lancet,  a  needle  was  ex- 
tracted from  the  middle  of  the  thigh  six  months  after 
it  had  been  swallowed,  and  like  instances  are  recorded 
elsewhere. 

Gastrotomy  and  gastrostomy. — Gastrotomy 
consists  in  opening  the  stomach  through  the  anterior 
abdominal  wall  for  the  purpose  of  removing  a  foreign 
body ;  gastrostomy,  in  opening  the  stomach  in  a  like 
situation  with  the  object  of  establishing  a  gastric 
fistula  through  which  the  patient  may  be  fed  in  cases 
where  the  gullet  is  occluded  by  disease.  The  un- 
covered part  of  the  stomach,  accessible  in  these  opera- 
tions, is  represented  by  a  triangular  area,  bounded  on 
the  right  by  the  edge  of  the  liver,  on  the  left  by  the 
cartilages  of  the  eighth  and  ninth  ribs,  and  below  by  a 
horizontal  line  passing  between  the  tips  of  the  tenth 
costal  cartilages  (Fig.  30).  The  incision  in  these  opera- 
tions must  be  situate  in  this  triangle,  and  may  be  made 
either  parallel  to,  and  about  two  fingers'  breadth  from, 
the  free  border  of  the  costae,  or  along  the  left  semi- 
lunar  line.  In  the  former  incision  the  three  flat 


332 


SURGICAL  APPLIED  ANATOMY.  [Chap. xvn 


Fig.  31.  -Diagram  to  show  the  Relations  of  the  Viscera  to  the  Parietes 

(Posterior  view), 
s,  Stomach;  t,  liver;  K,  kidney;  8  P,  spleen;  B,  rectum. 


Chap,  xvii.j          ABDOMINAL   VISCERA.  333 

muscles  of  the  abdomen  are  cut  through.  In  gastros- 
tomy  the  stomach  is  not  opened  at  the  time  of  the 
operation,  but  is  merely  secured  to  the  wound,  and  a 
few  days  are  then  allowed  to  elapse  so  that  adhesions 
may  form.  At  the  end  of  this  time  the  viscus  is 
opened.  Much  difficulty  is  occasioned  by  the  loose- 
ness of  the  mucous  membrane,  which  is  apt  to  pro- 
trude at  the  wound  by  reason  of  its  great  laxity. 

Resection  of  the  pytorus. — The  pylorus  is 
frequently  the  seat  of  cancer.  As  a  means  of  re- 
lieving the  patient  of  this  fatal  disease,  Billroth  and 
others  have  removed  the  whole  of  the  diseased 
pylorus,  and  have  then  united  by  sutures  the  cut 
ends  of  the  stomach  and  duodenum  and  closed  the 
abdominal  wound.  The  situation  of  the  cancerous 
pylorus  within  the  abdomen  varies  considerably,  as 
the  diseased  part  is  very  apt  to  shift  its  position.  It  is 
often  found  to  have  sunk  down  by  its  weight  to  a 
point  below  the  umbilicus,  and  to  have  contracted 
adhesions  to  adjacent  organs.  The  usual  incision  is 
oblique  in  direction,  is  about  four  or  five  inches  in 
length,  and  is  commonly  made  across  the  middle  line 
just  above  the  umbilicus.  The  diseased  part  has  to 
be  isolated  and  the  omental  connections  of  the  right 
end  of  the  stomach  freely  divided.  The  vessels  that 
are  almost  certainly  divided  are  the  pyloric,  the 
gastro-epiploica  dextra,  and  the  gastro-duodenal.  The 
cancer  is  excised,  and  the  cut  end  of  the  duodenum 
united  to  the  cut  edges  of  the  stomach,  so  as  to  re- 
establish the  canal.  The  details  of  the  operation  are 
very  complicated,  and  need  not  be  here  more  fully 
dealt  with,  further  than  to  say  that  since  the  section 
of  the  stomach  must  be  much  greater  than  that  of  the 
duodenum,  the  aperture  in  the  former  viscus  is  united 
by  sutures  until  the  gap  left  is  equivalent  in  calibre  to 
that  of  the  divided  duodenum. 

Other  operations  on  the  stomach.  —  If   a 


334  SURGICAL  APPLIED  ANATOMY.  [Chap.xvn. 

pyloric  cancer  be  too  large  or  otherwise  unsuited  for 
removal,  the  canal  of  the  alimentary  passage  may  be 
restored  by  gastro-enierostomy.  Here  the  stomach  is 
exposed.  An  incision  is  made  in  its  long  axis 
about  two  inches  from  the  greater  curvature,  a  con- 
venient coil  of  small  intestine  (jejunum)  is  taken,  is 
opened  along  its  free  border,  and  the  mai-gins  of  the 
gastric  and  intestinal  openings  are  then  adjusted. 
Food  can  now  pass  from  the  stomach  to  the  bowel 
without^passing  the  pylorus.  Loreta's  operation. — In 
cases  of  non-malignant  stricture  of  the  pylorus,  the 
stomach  has  been  opened  and  the  stricture  successfully 
dilated  by  two  fingers  introduced  through  the  wound. 
After  the  dilatation,  the  gastric  and  abdominal  wounds 
are  closed. 

The  small  intestines.* — The  average  length  of 
the  small  intestine  in  the  adult  is  22|  feet,  the  ex- 
tremes being  30  feet  and  15  feet.  In  the  foetus,  at 
full  term,  the  lesser  bowel  measures  about  9|  feet.  It 
is  roughly  reckoned  that  the  first  8  or  9  feet  of  the 
adult  bowel  belongs  to  the  jejunum,  and  the  remain- 
ing 12  or  13  feet  to  the  ileum. 

The  division  into  jejunum  and  ileum  is  quite  arbi- 
trary. There  is  no  one  point  where  it  can  be  said 
that  the  jejunum  ends  and  the  ileum  commences. 
When  the  small  intestines  are  exposed  by  accident  or 
operation,  it  is  often  difficult,  especially  when  there 
is  abdominal  disease,  to  recognise  the  upper  from  the 
lower  part  of  the  gut.  It  may  be  noted,  however, 
that  the  jejunum  is  wider  than  the  ileum  (its  diameter 
being  a  quarter  of  an  inch  greater  than  that  of  the 
ileum),  and  its  ooats  are  thicker  and  more  vascular. 
If  the  gut  be  empty,  and  can  be  rendered  translucent 
by  being  held  against  a  light,  the  lines  of  the  valvuhe 

*  The  account  of  the  intestines  is  derived  from  the  Author's 
work  "On  the  Intestinal  Canal  and  Peritoneum  in  Man. "  London, 
1885. 


chap,  xvii.j          ABDOMINAL   VISCERA.  335 

conniventes  can  be  well  seen.  These  folds  are  large 
and  numerous  in  the  jejunum,  but  become  small  and 
scanty  in  the  upper  ileum,  and  are  wanting  in  the 
lower  third  of  that  bowel.  Injuries  to  the  jejunum 
are  more  serious  than  are  those  of  the  ileum,  since  an 
intestinal  lesion  is  (other  things  being  equal)  the  more 
serious  the  nearer  it  approaches  to  the  stomach.  The 
fatality  of  umbilical  herniae  probably  depends  in  part 
upon  the  fact  that  the  contained  bowel  is  often 
jejunum.  The  coils  of  small  intestine  occupy  no 
certain  position  in  the  abdomen.  In  the  fetus,  and 
during  the  earliest  part  of  extra-uterine  life,  the  bulk 
of  the  small  intestine  is  placed  to  the  left  of  the  middle 
line.  This  is  on  account  of  the  relatively  large  size 
of  the  liver,  to  the  weight  of  which  the  lesser  bowel 
no  doubt  acts  as  a  counterpoise.  In  the  majority  of 
adult  bodies  the  small  intestine  is  disposed  in  an 
irregularly  curved  manner  from  left  to  right.  The 
gut,  starting  from  the  duodenum,  will  first  occupy  the 
contiguous  parts  of  the  left  side  of  the  epigastric  and 
umbilical  regions  ;  the  coils  then  fill  some  part  of  the 
left  hypochondriac  and  lumbar  regions  ;  they  now  com- 
monly descend  into  the  pelvis,  re-appear  in  the  left 
iliac  quarter,  and  then  occupy  in  order  the  hypogastric, 
lower  umbilical,  right  lumbar,  and  right  iliac  regions. 
Before  reaching  the  latter  situation  they  commonly 
descend  again  into  the  pelvis. 

Much  interest  attachas  to  the  coils  of  small  in- 
testine that  are  found  in  the  pelvis.  These  are  the 
coils  that  are  apt  to  become  involved  and  adherent  in 
cases  of  pelvic  peritonitis,  and  that  would  probably 
form  the  protrusion  in  most  cases  of  obturator,  sciatic, 
and  pudeudal  hernia.  No  small  intestine  occupies  the 
foetal  pelvis.  The  amount  found  in  the  adult  pelvis 
depends  mainly  upon  the  state  of  distension  of  the 
bladder  and  rectum,  and  upon  the  position  of  the 
sigmoid  flexure.  The  coils  that  are  most  usually 


336  SURGICAL  APPLIED  ANATOMY.  [Chap.xvn. 

found  in  this  position  belong  to  the  terminal  part  of 
the  ileum,  and  to  that  part  of  the  intestine  that  has 
been  already  alluded  to  as  possessing  the  longest 
mesentery  (page  325).  The  ileum  is  the  part  of  the 
intestine  that  is  most  frequently  found  in  inguinal 
and  femoral  hernise.  It  is  also  the  part  most  usually 
involved  in  cases  of  strangulation  by  internal  bands, 
by  holes  in  the  mesentery,  etc. 

Of  all  the  viscera  the  small  intestines  are  the  most 
exposed  to  injury,  and  at  the  same  time  it  must  be 
noted  that  by  their  elasticity,  and  by  the  ease  with 
which  their  coils  slide  over  one  another  and  so  elude 
the  effects  of  pressure,  they  are  the  best  adapted  to 
meet  such  injuries  as  contusions  and  the  like.  A 
minute  punctured  wound  of  the  small  gut  does  not 
lead  to  extravasation  of  contents.  The  muscular  coat 
contracts  and  closes  the  little  opening.  Thus,  in  ex- 
cessive tympanitis  the  bowels  are  often  freely  punc- 
tured in  many  places  with  a  fine  capillary  trochar,  to 
allow  the  gas  to  escape,  without  any  evil  resulting.  A 
case  of  intestinal  obstruction  of  sixteen  weeks'  dura- 
tion is  reported,  in  which  the  abdomen  was  punctured 
150  times  (Boston  Med.  Journ.).  If  the  wound  be  a 
little  larger  the  loose  mucous  membrane  becomes 
everted  or  protruded  through  the  wound  and  effec- 
tually plugs  it.  Gross  found  that  a  longitudinal  cut 
in  the  small  bowel  two  and  a  half  lines  in  length  was 
immediately  reduced  to  a  wound  one  and  three- 
quarter  lines  in  length  by  muscular  contraction,  and 
that  the  eversion  of  the  mucous  membrane  in  addition 
to  this  contraction  entirely  sealed  the  opening. 

Owing  to  the  greater  power  of  the  circular  layer 
of  muscle  a  longitudinal  wound  gapes  more  than  a 
transverse  wound,  and,  in  consequence  of  the  greater 
muscular  development  of  the  jejunum,  wounds  of  that 
part  gape  more  than  do  those  of  the  ileum.  Trans- 
verse wounds  gape  most  when  inflicted  across  the  free 


chap,  xvii.]          ABDOMINAL   VISCERA.  337 

border  of  the  gut,  since  in  that  place  the  longitudinal 
muscular  fibres  are  thickest. 

In  one  remarkable  case  a  man  was  stabbed  in  the 
belly.  It  was  subsequently  found  that  there  was  a 
small  puncture  in  the  ileum,  which  had  been  plugged 
by  the  mucous  membrane,  and  further  secured  by 
recent  lymph.  The  man  did  well  until  the  fourth 
day,  when  he  died  somewhat  suddenly.  It  was  then 
found  that  an  intestinal  worm  (Ascaris  lumbricoides) 
had  worked  its  way  through  the  wound,  breaking 
down  the  adhesions,  and  had  escaped  into  the  peri- 
toneal cavity.  Extravasation  followed,  and  thus  the 
worm  was  the  immediate  cause  of  the  man's  death. 

The  calibre  of  any  portion  of  the  small  intestine 
depends  mainly  upon  the  condition  of  its  muscular 
wall.  The  tube  may  become  much  contracted  when 
empty.  In  peritonitis  and  in  certain  other  conditions 
the  muscular  coat  is  paralysed  and  the  bowel  becomes 
intensely  dilated  by  gas  (tympanitis). 

deckel's  diverticulum. — From  one  to  four 
feet  from  the  end  of  the  ileum  is  sometimes  seen  a 
diverticulum  (Meckel's)  that  represents  the  remains  of 
the  vitello-intestinal  duct.  It  may  be  expected  in 
2  per  cent,  of  the  bodies  examined.  This  diverti- 
culum usually  exists  as  a  tube  of  the  same  structure 
as  the  intestine.  Its  length  varies.  It  may  some- 
times extend  as  a  patent  tube  as  far  as  the  umbilicus. 
It  is  more  often  but  a  few  inches  long,  and  may  then 
end  in  a  free  conical  or  globular  extremity,  or  in  a 
fibrous  cord.  This  diverticulum  may  cause  intestinal 
obstruction  in  many  ways.  Its  end  may  contract 
adhesions,  and  beneath  the  bridge  thus  formed  a  loop 
of  bowel  may  be  strangled.  It  may  twist  itself  about  a 
piece  of  intestine  so  as  to  form  a  knot  around  it.  It  may, 
from  its  adhesions,  so  drag  upon  the  ileum  as  to  cause 
"  kinking  "  of  the  tube  at  its  point  of  origin.  In  more 
than  one  case  it  has  been  found  in  an  external  hernia. 
W — 4 


338  SURGICAL  APPLIED  ANATOMY.  [Chap. xvn. 

The  duodenum  and  fossa  diiodeno- 
jejnnalis. — The  first  portion  of  the  duodenum  is 
nearly  horizontal.  It  measures  about  two  inches  in 
length  and  passes  backwards  from  the  pylorus  to  near 
the  upper  end  of  the  right  kidney.  The  second 
portion,  about  three  inches  in  length,  descends  verti- 
cally in  front  of  the  inner  border  of  the  right  kidney 
to  the  level  of  the  third  lumbar  vertebra.  The  third 
portion,  some  five  inches  in  length,  crosses  from 
right  to  left  in  front  of  the  third  vertebra,  and  then 
ascends  for  a  short  distance  on  the  surface  of  the  left 
psoas  muscle,  to  end  in  the  jejunum  to  the  left  of  the 
second  lumbar  vertebra.  The  first  portion,  which  is 
movable,  is  invested  by  peritoneum,  in  the  same 
manner  as  the  stomach.  The  second  part  is  covered 
by  peritoneum  in  front  only,  except  at  the  spot  where 
it  is  crossed  by  the  transverse  colon.  The  third  pai't 
is  also  covered  by  peritoneum  only  on  its  anterior 
aspect,  this  membrane  being,  however,  free  of  the 
gut  where  the  superior  mesenteric  vessels  cross  it. 

The  first  portion  has  found  its  way  into  hernise  in 
company  with  the  stomach,  but  the  second  and  third 
parts  are  never  herniated.  The  end  of  the  duodenum, 
the  duodeno-jejunal  bend,  is  very  firmly  held  in  place 
by  a  band  of  fibrous  tissue  that  descends  upon  it  from 
the  left  crus  of  the  diaphragm  and  the  tissue  about 
the  cceliac  axis.  This  band  is  called  the  suspensory 
muscle  of  the  duodenum  (Treitz).  It  serves  also  to 
support  the  mesentery.  No  matter  to  what  extent 
the  stomach  may  be  displaced  by  distension,  or  the 
intestines  disturbed  by  a  like  cause,  the  position  of  the 
duodeno-jejunal  bend  will  be  found  to  remain  un- 
altered. All  sections  of  the  duodenum  have  been- 
ruptured  by  violence.  Owing  to  its  large  non-peri- 
toneal surface,  the  bowel,  if  approached  from  behind, 
may  be  wounded  without  opening  the  peritoneum 
(Fig.  33). 


chap,  xvii.]          ABDOMINAL   VISCERA.  339 

In  connection  with  the  spread  of  disease  by  con- 
tinuity of  tissue,  it  is  well  to  note  that  the  duodenum 
is  in  relation  with  the  liver,  gall  bladder,  pancreas, 
transverse  colon,  spine,  right  kidney,  bile  duct,  portal 
vein,  gastro-duodenal  and  superior  mesenteric  vessels, 
aorta  and  vena  cava. 

In  the  duodenum  are  Brunner's  glands,  which  are 
sometimes  the  seat  of  a  perforating  ulcer  in  cases  of 
burns.  They  are  mostly  seated  in  the  first  segment 
of  this  bowel,  and  the  perforation,  therefore,  usually 
opens  into  the  peritoneal  cavity. 

The  peculiar  vertical  curve  of  the  duodenum 
closely  resembles  that  of  the  syphon  trap  used  in 
drains.  Mr.  Mayo  Collier  has  pointed  out  that  this 
part  of  the  bowel  probably  acts  as  a  real  syphon  trap, 
and  so  prevents  the  regurgitation  of  intestinal  gas 
into  the  stomach.  The  duodenum  of  the  horse  appeal's 
to  act  also  in  this  manner. 

Passing  from  the  front  of  the  terminal  (ascending) 
part  of  the  duodenum,  a  fold  of  peritoneum  is  often 
seen,  that  joins  the  parietal  peritoneum  to  the  left  of 
the  piece  of  gut  in  question.  This  fold  marks  off  a 
fossa  of  triangular  outline,  the  orifice  of  which  is 
directed  upwards.  I  have  found  the  fossa  in  about 
50  per  cent,  of  the  bodies  examined.  It  is  called  the 
fossa  duodeno  -jejuualis ;  it  is  usually  large 
enough  to  lodge  the  tip  of  the  finger,  and  its  opening 
lies  just  below  the  duodeno-jejunal  bend.  This  fossa 
is  the  anatomical  cause  of  mesenteric  or  retro-peritoneal 
hernia.  The  commencement  of  the  jejunum  pi-esses 
into  the  fossa,  enlarges  its  cavity,  and  ultimately 
separates  the  peritoneum  from  its  posterior  attach- 
ments. More  and  more  of  the  small  intestine  passes 
into  the  increasing  pouch,  until  at  last,  as  in  the 
case  reported  by  Sir  Astley  Cooper,  nearly  the 
whole  of  the  small  intestine  may  be  found  lodgfil 
in  an  enormous  median  retro-peritoneal  sac,  the 


340  SURGICAL  APPLIED  ANATOMY.  [Chap. xvn. 

inouth  of  which  is  the  orifice  of  the  fossa  duodeno- 
jejunalis. 

In  the  meso-colic  hernia  of  Cooper  the  small  in- 
testine is  found  also  in  a  retro-peritoneal  sac.  This 
•sac,  however,  is  to  the  left  of  the  middle  line,  and  is 
developed  at  the  expense  of  the  peritoneum  leading  to 
the  descending  colon.  It  has  nothing  to  do  with  the 
fossa  just  described,  but  is  due  to  the  enlargement  of 
a  deep  pouch  that  I  have  described  as  occasionally 
existing  in  the  parietal  peritoneum  leading  to  the 
descending  colon.  The  mouth  of  the  pouch  is  directed 
upwards,  and  is  skirted  by  a  branch  of  the  inferior 
mesenteric  artery. 

Liaparotomy. — In  this  procedure  the  abdomen  is 
opened  from  in  front  for  the  purpose  of  exploration, 
or  for  the  relief  of  a  piece  of  bowel  strangulated  by  a 
band,  and  under  certain  other  circumstances.  It  much 
more  frequently  concerns  the  small  bowel  than  the 
large.  The  incision  is  usually  made  in  the  middle 
line  below  the  umbilicus,  and  a  cut  from  three  to 
four  inches  long  is  usually  found  to  be  sufficient.  It 
may  be  made  in  either  of  the  semilunar  lines  or 
over  any  spot  especially  indicated  by  the  disease. 
Enterotomy  is  the  operation  of  opening  the  small  in- 
testine above  some  obstruction  that  threatens  to  be 
fatal  or  insuperable.  The  incision  is  made  in  the 
linea  alba,  below  the  umbilicus,  or  in  one  or  other 
iliac  region,  as  is  considered  more  convenient.  An 
incision  some  three  inches  in  length  will  probably 
suffice.  The  peritoneum  having  been  opened,  a 
knuckle  of  small  bowel  close  above  the  obstruction  is 
seized,  is  secured  to  the  parietal  wound,  and  then 
opened.  The  small  intestine  has  also  been  opened  to 
remove  impacted  foreign  bodies  and  large  gall  stones. 
In  such  cases  the  intestinal  wound  is  closed  imme- 
diately. Enterectomy. — Portions  of  the  small  intes- 
tine have  been  resected  with  success  for  various 


chap,  xvii.j          ABDOMINAL   VISCERA.  341 

diseased  conditions.  In  one  case  more  than  two  yards 
of  the  small  intestine  were  cut  away  on  account  of 
multiple  stricture.  The  patient,  a  young  woman, 
made  an  excellent  recovery.  Resections  have  also 
been  successfully  performed  in  cases  of  bullet  wound 
or  stab  involving  the  lesser  bowel. 

In  uniting  divided  intestine  by  suture  (enteroraphy) 
it  is  essential  that  the  serous  coat  of  the  ends  of  the 
bowel  should  be  brought  together.  This  is  best  effected 
by  the  suture  known  as  Lembert's.  Experience  shows 
that  if  leakage  occurs  after  resection  or  suture  of  in- 
testine it  will  most  likely  occur  along  the  attachment 
of  the  mesentery.  This  circumstance  is  thus  explained 
by  Mr.  Anderson.  The  two  layers  of  the  mesentery 
diverge  as  they  approach  the  bowel,  and  so  leave  a 
ti'iangular  space,  the  base  of  which,  averaging  about 
Tyths  of  an  inch  in  width,  is  formed  by  the  uncovered 
muscular  tissue.  It  is  the  existence  of  this  bare  piece 
of  intestine  that  renders  adjustment  of  the  serous  coat 
at  the  attachment  of  the  mesentery  a  matter  of  some 
difficulty. 

The  ileo-caecal  region. — The  caecum  is,  to  a 
certain  extent,  rudimentary  in  man,  as  it  is  also  in 
the  carnivora.  In  herbivorous  animals  it  is  of  great 
size,  and  appears  to  serve  as  a  reservoir  for  the  elabo- 
ration and  absorption  of  food.  It  has  been  said  that 
the  caecum  in  man  exists  as  an  anatomical  protest 
against  vegetarianism.  The  appendix  persists  as  the 
remains  of  the  larger  caecum  of  lower  mammals.  In 
the  human  foetus  it  can  be  seen  to  be  but  the  narrowed 
extremity  of  a  capacious  caecum.  The  foetal  type  of 
caecum,  which  is  very  characteristic,  may  persist 
throughout  life.  From  the  point  of  view  of  evolution, 
the  appendix  would  appear  to  be  becoming  obliterated. 
Like  other  functionless  parts  that  persist  a?  develop- 
mental relics,  it  is  very  frequently  the  seat  of  disease, 
and  it  is  worthy  of  note  that  such  disease  tends  tc 


34*  SURGICAL  APPLIED  ANATOMY,  tchap.xvn. 

cause  the  entire  obliteration  of  the  part  (as  after  many 
forms  of  so  called  typhlitis). 

It  must  be  understood  that  the  term  ccecum  is 
applied  to  that  part  of  the  colon  that  lies  below  the 
entrance  of  the  ileum.  The  average  breadth  of  the 
adult  caecum  is  3  inches,  its  average  length  (vertical 
measurement)  2^  inches. 

The  caecum  is  usually  lodged  in  the  right  iliac 
fossa,  and  is  so  placed  that  its  apex  corresponds  with 
a  point  a  little  to  the  inner  side  of  the  middle  of 
Poupart's  ligament. 

A  slightly  distended  caecum  so  located  may  be 
emptied  by  flexing  the  thigh  upon  the  abdomen.  The 
caecum  is  always  entirely  invested  by  peritoneum.  Its 
posterior  surface  is  never  in  connection  with  the 
areolar  tissue  of  the  iliac  fossa.  The  peritoneum  is 
reflected  from  the  commencement  of  the  ascending 
colon  on  to  the  posterior  parietes.  The  line  of  this 
reflection  varies,  but  is  usually  about  a  transverse 
line  between  the  level  of  the  anterior  superior  iliac 
spine  and  the  summit  of  the  iliac  crest.  The  mobility 
of  the  caecum  depends  mainly  upon  two  conditions, 
either  upon  the  length  of  intestine  that  extends 
between  the  tip  of  the  caecum  and  the  reflection  of  the 
peritoneum  above  alluded  to,  or  upon  the  presence  of 
an  ascending  meso-colon.  A  mobile  caecum  may  hang 
over  the  pelvic  brim,  or  occupy  the  pelvis,  or  even 
find  its  way  into  an  inguinal  hernia  of  the  left  side. 

The  caecum  is  not  infrequently  found  in  an  inguinal 
or  femoral  hernia  of  the  right  side  (caecal  hernia). 
Such  hernia?  are,  except  in  a  few  rare  instances, 
provided  with  a  proper  and  complete  peritoneal  sac. 

Foreign  bodies  that  have  been  swallowed  are  very 
apt  to  lodge  in  the  caecum,  and  in  that  situation  may 
cause  ulceration  and  even  perforation  of  the  bowel, 
producing  one  form  of  typhlitis. 

In    cases    of    faecal    retention,    also,    the    largest 


chap,  xvn.]         ABDOMINAL   VISCERA.  343 

accumulation  of  faecal  matter  is  very  usually  met  with 
in  the  caecum,  and  upon  that  part  of  the  bowel  when 
distension  is  extreme  the  greatest  strain  usually 
comes. 

Stercoral  ulcers  (ulcers  due  to  the  pressure  and 
irritation  of  retained  faeces)  are  more  often  met  with 
in  the  caecum  than  in  any  other  part  of  the  colon. 
Intestinal  concretions  also  are  not  uncommon  in  this 
part. 

The  caecum  is  susceptible  of  enormous  distension, 
provided  that  it  be  gradually  effected,  and,  in  certain 
instances,  a  dilated  caecum  has  been  found  to  occupy 
a  large  part  of  the  abdominal  cavity.  When  the 
abdomen  is  opened  in  any  doubtful  case  of  intestinal 
obstruction  the  condition  of  the  caecum  is  of  great 
value  in  pointing  to  the  seat  of  the  obstacle.  In 
stenosis  of  the  colon  it  will  be  found  greatly  distended, 
while  in  obstruction  of  the  small  gut  it  will  be  empty, 
or,  at  least,  in  a  normal  condition. 

The  appendix  varies  in  length.  Its  average  measure- 
ment in  the  adult  is  four  inches,  the  extremes  being 
one  inch  and  six  inches.  Its  position  varies,  although, 
as  a  rule,  it  is  seen  to  lie  behind  the  end  of  the  ileum 
and  its  mesentery,  and  to  point  in  the  direction  of  the 
spleen.  It  frequently  also  lies  behind  the  caecum.  I 
have  seen  the  appendix  so  placed  with  reference  to 
the  bowel  that  it  would  have  been  encountered  in  a 
right  lumbar  colotomy.  It  has  found  its  way  down 
both  the  right  and  the  left  inguinal  canals. 

The  tip  of  the  process  may  adhere  to  a  neighbour- 
ing peritoneal  surface,  and  thus  form  a  "  band,"  be- 
neath which  a  piece  of  small  intestine  may  be 
strangulated. 

Foreign  bodies  are  very  apt  to  lodge  in  the 
appendix,  and  it  is  very  often  found  to  be  occupied  by 
a  faecal  concretion  or  calculus.  These  substances 
excite  inflammation,  and,  as  a  result,  the  appendix 


344  SURGICAL  APPLIED  ANATOMY,  ia-.ap.xvu. 

may  become  perforated.  Troubles  in  the  vermiform 
process  are  the  most  frequent  causes  of  typhlitis  or 
perityphlitis.  These  terms  are  applied  to  localised 
inflammation  of  the  peritoneum  in  the  vicinity  of  the 
csecum. 

It  is  in  the  ileo-csecal  region  that  intussusception 
most  frequently  occurs.  In  this  condition  one  part  of 
the  intestine  is  prolapsed  or  "  telescoped  "  into  the 
lumen  of  an  immediately  adjoining  part.  In  the  ileo- 
csecal  vaiiety  (the  commonest  form)  the  narrow  ileurn, 
and  subsequently  the  caecum,  are  prolapsed  into  the 
colon.  The  ileo-caecal  valve  forms  the  summit  of  the 
protrusion  or  intussusceptum.  By  a  gradual  increase 
of  the  condition  the  intussuscepted  bowel  may  at  last 
reach  the  rectum,  and  the  ileo-caecal  valve  has,  in  fact, 
been  recognised  protruding  from  the  anus.  In  the 
ileo-colic  variety  (the  rare  form)  the  end  of  the  ileuin 
is  prolapsed  through  the  valve.  The  valve  and  the 
caecum  remain  in  their  normal  situations,  and  the 
summit  of  the  intussusceptum  is  formed  only  by  the 
ileum. 

The  large  intestine. — From  the  caecum  to  the 
sigmoid  flexure,  this  portion  of  the  bowel  is  accessible 
to  pressure  except  at  the  hepatic  and  splenic  flexures, 
which  are  deeply  placed.  The  hepatic  flexure  is 
under  the  shadow  of  the  liver,  and  the  splenic  curve, 
which  reaches  a  higher  level,  is  behind  the  stomach. 
The  position  of  the  transverse  colon  can  often  be  well 
marked  out.  It  crosses  the  belly  transversely,  so  that 
its  lower  border  is  on  a  level  with  the  umbilicus  (Fig. 
30).  In  cases  of  faecal  accumulation,  the  outline  of  the 
colon,  with  the  exception  of  the  two  flexures  above 
named,  may  be  distinctly  defined.  In  distension  of  the 
small  intestine  the  belly  tends  to  present  the  greatest 
degree  of  swelling  in  front,  and  about  and  below 
the  navel.  In  distension  of  the  Im-ger  gut,  the  front 
of  the  abdomen  may  remain  (for  a  while  at  lease) 


Chap,  xvii.]          ABDOMINAL   VISCERA.  345 

comparatively  flat,  while  the  distension  will  be  most 
obvious  in  the  two  flanks  and  in  the  region  just  above 
the  umbilicus.  Tumours  of  the  transverse  colon,  and 
of  the  lower  two-thirds  of  the  ascending  and  descend- 
ing colon,  can  be  well  denned,  even  when  of  moderate 
size,  and  in  cases  of  intussusception  the  progress  of  the 
mass  along  the  colon  can  often  be  traced  with  great 
ease,  and  the  effects  of  enemata  and  other  methods  of 
reduction  carefully  watched.  The  diameter  of  the  large 
intestine  (excluding  the  rectum)  gradually  diminishes 
from  the  caecum  to  the  sigmoid  flexure,  the  diameter 
of  the  former  being  about  two  and  a  half  inches,  of  the 
latter  one  and  a  half  inches.  The  narrowest  part  of  this 
segment  of  the  bowel  is  at  the  point  of  junction  of  the 
sigmoid  flexure  with  the  rectum,  and  it  is  significant 
that  it  is  at  this  point  that  stricture  is  the  most 
common. 

The  tendency  to  stricture  increases  as  one  proceeds 
downwards  from  the  caecum  to  the  anus.  A  stricture 
is  frequent  in  the  descending  colon,  less  frequent  in  the 
transverse  colon,  while  in  the  ascending  colon  it  is 
comparatively  rare.  Strictures  are  not  uncommon 
about  the  flexures  of  the  bowel.* 

When  gradually  distended  the  colon  may  assume 
enormous  dimensions,  and  it  will  be  readily  understood 
that  in  some  cases  of  great  fiscal  accumulation  the 
thoracic  organs  may,  with  certain  abdominal  viscera, 
be  displaced.  In  one  case,  for  example,  the  heart  was 
so  displaced  by  the  distended  colon  that  the  apex  beat 
was  found  to  be  one  and  a  half  inches  above  and  one 
inch  to  the  inner  side  of  the  left  nipple.  When  the 
fajcal  collection  had  been  removed  it  returned  to  its 
normal  position.  Thus  it  happens  that  a  distended 
colon  is  often  associated  with  shortness  of  breath,  with 
palpitation,  and  other  thoracic  symptoms. 

*  See  "Intestinal  Obstruction."  By  the  Author.  London, 
MM* 


346  SURGICAL  APPLIED  ANATOMY,  tchap.xvn. 

The  ascending  and  the  descending  colon  are  placed 
vertically.  The  average  length  of  the  ascending 
colon  in  the  adult  (as  measured  from  the  tip  of  the 
caecum  to  the  hepatic  flexure)  is  8  inch es.*i The  average 
length  of  the  descending  colon  (from  the  splenic  bend 
to  the  commencement  of  the  sigmoid  flexure)  is  Si- 
inches.  The  descending  colon  is  very  little  liable  to 
variation.  In  cases  of  non-descent  of  the  caecum  the 
ascending  colon  may  be  absent  (page  349).  I  have 
pointed  out  that  in  fifty-two  per  cent,  of  adult 
bodies  there  is  neither  an  ascending  nor  a  descending 
meso-colon,  and  that  a  meso-colon  may  be  expected  on 
the  left  side  in  thirty-six  per  cent,  of  all  cases,  and  on 
the  right  side  in  twenty-six  per  cent.  These  points 
are  of  importance  in  connection  with  lumbar  colotomy. 
The  breadth  of  the  meso-colon,  when  it  exists,  varies 
from  one  to  three  inches.  The  line  of  attachment  of 
the  left  meso-colon  is  usually  along  the  outer  border  of 
the  kidney,  and  is  vertical.  That  of  the  right  meso- 
colon  is,  as  a  rule,  less  vertical,  runs  along  the  inner 
border  of  the  kidney,  and  crosses  its  lower  end  ob- 
liquely from  right  to  left. 

The  transverse  colon  has  an  average  measurement 
of  twenty  inches.  It  is  not  quitejiorizontal,  since  the 
splenic  flexure  is  on  a  higher  level  than  the  hepatic 
flexure,  as  well-  as  posterior  to  it.  Faecal  masses 
lodged  in  the  transverse  colon  have  given  rise  to  many 
errors  in  diagnosis.  In  some  instances  this  part  of  the 
colon  is  displaced  towards  the  pelvis,  so  that  V  or 
U-shaped  bends  are  produced.  In  such  cases  the 
point  of  the  V  or  U  may  reach  the  symphysis  pubis, 
while  the  two  colic  flexures  occupy  their  proper  situa- 
tions. These  deviations  are  described  in  detail  in  my 
work  on  Intestinal  Obstruction. 

The  right-hand  part  of  the  transverse  colon  is  in 
intimate  relation  with  the  gall  bladder,  and  is  commonly 
found  to  be  bile- stained  after  death.  Jn  some  cases 


chap,  xvii.)          ABDOMINAL   VISCERA.  347 

where  gall  stones  have  been  lodged  within  the  gall 
bladder,  the  walls  of  that  structure  have  ulcerated 
from  pressure,  the  ulceration  has  involved  the  sub- 
jacent transverse  colon,  and  thus  a  fistula  has  been 
established  between  the  gall  bladder  and  the  gut, 
through  which  large  stones  have  been  passed.  Hepatic 
abscesses  also  have  discharged  themselves  through  the 
transverse  colon. 

The  sigmoid  flexure. —  The  segments  of  gut  termed 
the  sigmoid  flexure  and  "the  first  part  of  tho 
rectum,"  form  together  a  single  simple  loop  that 
cannot  be  divided  into  parts.  This  loop  begins  where 
the  descending  colon  ends,  and  ends  at  the  commence- 
ment of  the  so-called  "  second  part  of  the  rectum  ; "  at 
a  spot,  in  fact,  where  the  meso-rectum  ceases,  opposite 
about  the  third  piece  of  the  sacrum.  This  loop,  when 
unfolded,  describes  a  figure  that,  if  it  must  be  com- 
pared to  a  letter,  resembles  the  capital  Omega.  It  may 
well  be  termed  the  Omega  loop,  and  the  term  rectum 
be  limited  to  the  short  piece  of  practically  straight  gut, 
that  is  now  described  as  the  second  and  third  parts  of 
the  rectum.  The  average  length  of  the  loop  in  the 
adult  is  seventeen  and  a  half  inches.  The  two  ex- 
tremities of  the  loop  are  about  three  or  four  inches 
apart.  If  they  are  approximated  to  one  another,  as 
by  contracting  peritonitis  at  the  root  of  the  sigmoid 
meso-colon,  a  kind  of  pedicle  is  established,  about 
which  the  loop  may  readily  become  twisted.  Such  a 
twist  of  the  bowel  constitutes  a  volvulus  of  the 
sigmoid  flexure  ;  and  it  may  be  here  said  that  volvulus 
of  the  intestine  is  more  commonly  met  with  in  this 
loop  than  in  any  other  part  of  the  canal. 

The  line  of  attachment  of  the  meso-colon  of  the 
Omega  loop  (the  sigmoid  meso-colon)  crosses  the  psoas 
muscle  and  the  iliac  vessels  near  their  bifurcation  ;  it 
then  turns  abruptly  down,  and  running  nearly  ver- 
tically, terminates  at  the  middle  line. 


348  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvn. 

In  the  left  wall  of  this  meso-colon,  close  to  the 
point  where  it  lies  over  the  iliac  vessels,  a  fossa  is 
sometimes  to  be  found.  It  is  produced  by  the  sigmoid 
artery,  and  is  about  one  and  a  half  inches  in  depth.  It 
is  called  the  intersigmoid  fossa,  and  is  the  seat  of 
sigmoid  hernia.  Two  cases  of  strangulated  hernia  in 
this  fossa  have  been  recorded. 

The  sigmoid  flexure,  or  Omega  loop,  when  empty, 
normally  occupies  the  pelvis.  When  distended  this 
piece  of  bowel  may  become  so  enormously  dilated  as 
to  reach  the  liver.  The  chief  examples  of  extraor- 
dinary dilatation  of  the  colon  concern  this  loop. 
Faecal  masses  are  very  frequently  lodged  in  the  free 
end  of  the  loop,  and  certain  intestinal  concretions  have 
been  met  with  in  the  same  situation. 

I  have  shown  by  experiment  that  the  "  long  tube," 
when  introduced  through  the  anus,  cannot  be  passed 
beyond  the  sigmoid  flexure  in  ordinary  cases,  and 
with  a  normal  disposition  of  the  bowel. 

In  cases  of  congenital  absence,  or  deficiency  of  the 
rectum,  the  sigmoid  flexure  is  often  opened  in  the 
groin  and  an  artificial  anus  established  there.  This 
operation,  known  as  Littre's  operation,  is,  it  must  be 
confessed,  not  very  successful.  One  difficulty  has 
been  said  to  depend  upon  the  uncertain  position  of  the 
sigmoid  flexure  in  cases  of  congenital  deformity,  it 
being  sometimes  on  the  right  side  and  sometimes  in 
the  pelvis  at  the  middle  line.  It  is  rarely,  however, 
found  in  these  positions.  Out  of  100  post-mortem 
examinations  on  young  infants,  Curling  found  the  loop 
on  the  left  side  in  85  cases. 

Congenital  malformations  of  the  colon.— 
These  are  of  moment  with  regard  to  operative  pro- 
cedures. It  may  be  very  briefly  said  that  in  the  foetus 
the  small  bowel  occupies  at  one  time  the  right  side  of 
the  abdomen,  while  the  large  gut  is  represented  by  a 
straight  tube  that  passes  on  the  left  side  vertically 


Chap,  xvii.]          ABDOMINAL   VISCERA.  349 

from  the  region  of  the  umbilicus  to  the  pelvis.  The 
caecum  is  at  first  situated  within  the  umbilicus,  and  then 
ascends  in  the  abdomen  towards  the  left  hypochon- 
drium.  It  next  passes  transversely  to  the  right  hypo- 
chondrium,  and  then  descends  into  the  corresponding 
iliac  fossa.  It  may  be  permanently  arrested  at  any  part 
of  its  course.  Thus  the  caecum  may  be  found  about  the 
umbilicus,  or  in  a  congenital  umbilical  hernia,  or  in  the 
left  hypochondriac  region  (the  ascending  and  trans- 
verse parts  of  the  colon  being  absent),  or  it  may  be 
found  in  the  right  hypochondrium,  the  ascending 
colon  only  being  unrepresented.  The  whole  of  the 
large  intestine  has  at  one  time  an  extensive  mesentery, 
and  in  some  rare  cases  this  condition  may  persist 
throughout  life. 

Lumbar  colotomy. — The  operation  so  named 
consists  in  opening  the  colon  in  the  loin  behind  the 
peritoneum,  for  the  purpose  of  establishing  an  arti- 
ficial anus.  The  operation  is  performed,  when  possible, 
upon  the  left  side,  in  preference  to  the  right,  inasmuch 
as  the  descending  colon  is  nearer  to  the  anus.  The 
position  of  the  descending  colon  in  the  loin  may  be 
represented  by  a  line  drawn  vertically  upwards  from 
a  point  half-an-inch  behind  the  centre  of  the  iliac 
crest.  In  performing  left  lumbar  colotomy  an  ink  line 
may  be  drawn  vertically  upwards  from  the  centre  of 
the  crest  of  the  ilium.  It  will  hit  the  outer  end  of 
the  last  rib.  An  incision  is  made  across  the  centre  of 
this  line  parallel  to  the  last  rib,  and  so  planned  that 
the  centre  of  the  incision  corresponds  to  the  centre  of 
the  line.  The  superficial  tissues  having  been  incised, 
the  following  structures  are  then  divided  in  layers  in 
the  following  order  :  (1)  The  latissimus  dorsi  and 
external  oblique  nmscles  to  an  equal  extent.  (2)  The 
internal  oblique  in  the  entire  length  of  the  incision. 
(3)  The  fascia  lumborum,  with  a  few  of  the  most 
posterior  fibres  of  the  transversalis  muscle.  (4)  The 


35° 


SURGICAL  APPLIED  ANATOMV.  ICH&P.  xvn. 


transvevsalis  fascia.  The  quadratus  lumborum  will 
be  exposed  in  the  posterior  inch  or  so  of  the  incision, 
and  usually  does  not  need  to  be  cut.  At  the  seat  of 


Fig.  32. — Horizontal  Section  through  the  Body  at  the  Level  of  the 
Umbilicus.     (After  Braune.) 

o,  Spine  of  the  fourth  lumbar  vertebra  ;  4,  disc  between  third  and  fourth  verte- 
brae; c,  umbilicus;  d,  quadratus  lumborum;  e,  psoas;/,  external  oblique, 
with  internal  oblique  and  transversalis  muscles  beyond ;  g,  rectus ;  ft,  de- 
scending colon ;  i,  transverse  colon ;  j,  aorta ;  k,  inferior  vena  cava ;  I, 
ureter. 

the  operation  the  descending  colon  occupies  the  angle 
between  the  psoas  and  quadratus  lumborum  muscles, 
and  the  non-peritoneal  surface  is  exactly  represented 
by  that  part  of  the  bowel  that  faces  this  angle 
(Fig.  32).  Thus,  if  during  the  operation  the  curved 


Chan,  xvn.)          ABDOMINAL   VISCERA.  351 

finger  be  placed  in  this  angle,  and  the  patient  be 
rolled  over  to  the  left  side,  the  bowel  that  falls  into 
the  finger  cannot  well  be  other  than  the  descending 
colon.  The  gut  is  drawn  forwards,  stitched  to  the 
wound,  and  opened  by  a  transverse  cut.  The  width 
of  the  non-peritoneal  surface  varies  from  four-fifths 
of  an  inch  to  an  inch  in  the  empty  state,  and  may 
attain  to  two  inches  or  more  in  the  distended  con- 
dition (Braune).  The  part  of  the  descending  colon 
usually  opened  is  the  highest  portion  of  that  bowel,  so 
that  the  finger  can  often  be  thrust  into  the  transverse 
colon,  or  the  opening  of  that  intestine  can  be  seen. 
In  this,  as  in  other  circumstances,  the  large  bowel  may 
be  distinguished  from  the  small  by  its  sacculi,  its  three 
longitudinal  muscular  bands,  and  its  appendices  epi- 
ploicse.  As  regards  dimensions,  the  small  intestine 
may,  especially  in  cases  of  obstruction,  be  much  larger 
than  the  so-called  large  intestine.  When  empty,  the 
diameter  of  the  descending  colon  is  about  equal  to  that 
of  the  jejunum,  the  measurement  in  the  two  cases 
being  about  one  and  a  half  inches.  The  average  dia- 
meter of  the  ileum  is  one  and  a  quarter  inches,  and  of 
the  caecum  and  commencing  colon  two  and  a  half 
inches. 

Lumbar  colotomy  is  often  performed  through  a 
vertical  or  oblique  incision  in  the  place  of  the  one  just 
given. 

The  operation  does  not  materially  differ  from  that 
described,  when  it  is  performed  on  the  right  side. 

Iliac  or  inguinal  colotomy.— In  this  very 
excellent  and  simple  operation  the  sigmoid  flexure  is 
exposed  and  opened  in  the  left  iliac  region.  -  A  line 
is  drawn  from  the  anterior  superior  iliac  spine  to  the 
umbilicus,  and  an  incision  some  two  inches  in  length  is 
made  at  right  angles  to  this  line  and  at  a  distance  of 
about  one  and  a  half  inches  from  the  point  of  bone.  The 
three  muscles  of  the  abdomen  and  the  peritoneum 


352  SURGICAL  APPLIED  AK ATOMY.  [Chap. xvn. 

having  been  divided,  the  loop  of  the  sigmoid  flexure  is 
brought  into  the  wound,  is  secured,  and  is  (probably 
at  a  later  period)  opened. 

The  caecum  may  be  opened  upon  the  right  side, 
and  as  a  rule  the  most  convenient  incision  is  an  oblique 
one  placed  external  to  the  deep  epigastric  artery. 

Colectoniy  consists  in  resecting  a  portion  of  either 
the  ascending  or  descending  colon  that  is  the  seat  of  a 
carcinomatous  or  other  stricture.  It  is  most  con- 
veniently performed  in  the  lumbar  region,  and  then 
involves  the  formation  of  an  ai'tificial  anus  that  will 
probably  be  permanent.  Colectomy  may,  however,  be 
carried  out  thi-ough  an  incision  in  the  middle  line,  and 
may  concern  the  transverse  colon  ;  in  such  a  case  the 
ends  of  the  divided  bowel  are  united,  and  the  abdomi- 
nal wound  closed.*  Lumbar  colectomy  may  be  per- 
formed through  the  incision  pi-actisecl  in  colotorny. 

The  liver. — The  liver  is  moulded  to  the  arch  of  the 
diaphragm,  and  lies  over  a  part  of  the  stomach  (Fig. 
34).  The  convex  surface  is  protected  on  the  right  side 
by  the  ribs,  from  the  seventh  to  the  eleventh  inclusive, 
and  in  front  by  the  xiphoid  cartilage  and  the  costae 
from  the  sixth  to  the  ninth  inclusive,  the  diaphragm 
being  interposed.  The  diaphragm  separates  the  liver 
from  the  thin  margin  of  the  base  of  the  right  lung, 
which  descends  in  front  of  it.  It  extends  to  the  left 
about  one  and  a  half  inches  beyond  the  left  margin  of 
the  sternum.  In  the  middle  line  the  liver  lies  close 
beneath  the  skin  in  front  of  the  stomach,  and  reaches 
about  half  way  between  the  xiphoid  cartilage  and  the 
navel.  The  lower  edge,  ag  it  crosses  the  subcostal  angle, 
is  represented  by  a  line  drawn  from  the  ninth  right 
to  the  eighth  left  costal  cartilage  (Fig.  30).  In.  the 
erect  posture  the  lower  edge  on  the  right  side  is 
about  half  or  quarter  of  an  inch  below  the  margins  of  the 

*  See  "Resection  of  Portions  of  Intestine,"  bj  the  Author. 
Trans.  Royal  Mecl.-Chir.  Soc.,  1882. 


chap. xvii.]  ABDOMINAL   VISCERA,  353 

costal  cartilages.  In  the  recumbent  position  the  liver 
ascends  about  an  inch,  and  is  entirely  covered  by  the 
costae,  except  at  the  subcostal  angle.  It  descends  also 
in  inspiration  and  rises  in  expiration.  "  The  extent  of 
the  liver  upwards,  if  traced  on  the  surface  of  the  body, 
is  indicated  by  a  line  crossing  the  meso-sternum  close 
to  its  lower  end,  and  rising  on  the  right  side  to  the 
level  of  the  fifth  chondro-sternal  articulation,  and  on 
the  left  to  that  of  the  sixth  "  (Quain).  Behind,  the 
liver  conies  to  the  surface  below  the  right  lung,  at  a 
part  corresponding,  both  in  position  and  width,  to  the 
tenth  and  eleventh  dorsal  vertebrae.  On  the  extreme 
right  the  liver  descends  to  the  level  of  the  second 
lumbar  spine  (Figs.  31  and  33).  The  under  surface  of 
the  liver  is  in  contact  with  the  stomach,  the  first  and 
second  parts  of  the  duodenum,  the  small  omenturn, 
the  right  kidney,  and  the  beginning  of  the  transverse 
colon. 

The  fundus  of  the  gall  -  bladder  approaches  the 
surface  behind  the  ninth  costal  cartilage,  close  to  the 
outer  border  of  the  right  rectus  muscle. 

The  liver  is  more  often  ruptured  from  contusions 
than  is  any  other  abdominal  viscus.  This  is  explained 
by  its  large  size,  its  comparatively  fixed  position,  and 
its  great  friability  of  structure.  Death,  in  such  in- 
juries, usually  ensues  from  haemorrhage,  since  the  walls 
of  the  portal  and  hepatic  veins,  being  incorporated 
with  the  liver  substance,  are  unable  to  retract  or  to 
collapse.  The  hepatic  veins  also  open  direct  into  the 
vena  cava,  and,  being  unprovided  with  valves,  could 
allow  of  the  escape  of  an  immense  quantity  of  blood, 
if  any  retrograde  current  were  established.  It  is  pos- 
sible for  the  liver  to  be  ruptured  without  the  peritoneal 
coat  being  damaged.  -  Such  injuries  may  be  readily 
recovered  from.  The  liver  presents,  behind,  a  fairly 
extensive  non-peritoneal  surface,  at  which  rupture  or 
wound  may  occur  without  extravasation  into  the 
x— 4 


354  SURGICAL  APPLIED  ANATOMY.  [Chap. xvn. 

abdominal  cavity.  From  the  relation  of  the  liver  to 
the  right  lower  ribs,  it  follows  that  this  viscus  may  be 
damaged  when  the  ribs  are  fractured,  and  in  some 
cases  the  broken  ends  of  the  bones  have  been  driven 
through  the  diaphragm  into  the  liver  substance.  Stabs 
through  the  sixth  or  seventh  right  intercostal  space, 
over  the  liver  region,  would  wound  both  the  lung  and 
the  liver,  would  involve  the  diaphragm,  and  open  up 
both  the  pleural  and  }>eritoneal  cavities.  The  intimate 
relation  of  the  liver  to  the  transverse  colon  is  illus- 
trated by  a  case  where  a  toothpick,  four  inches  in 
length,  was  found  in  the  substance  of  the  liver.  It 
had  worked  its  way  there,  from  the  colon,  along  an 
abscess  cavity  that  connected  the  two  viscera.  The 
relation  of  the  liver  to  the  heart  may  be  illustrated  by 
a  case  still  more  remarkable.  In  this  instance  a  loose 
piece  of  liver,  weighing  one  drachm,  was  found  in  the 
pulmonary  artery.  The  patient  had  been  crushed 
between  two  waggons,  the  liver  was  ruptured,  and  the 
diaphragm  torn.  A  piece  of  the  liver  had  been 
squeezed  along  the  vena  cava  into  the  right  auricle, 
whence  it  had  passed  into  the  right  ventricle,  and  so 
into  the  pulmonary  artery.  The  heart  itself  was  quite 
uninjured.  Portions  of  the  liver  may  protrude  through 
abdominal  wounds,  and  are  usually  easy  to  reduce.  In 
one  instance  of  such  protrusion  the  surgeon  did  not 
find  the  reduction  easy,  so  he  placed  a  ligature  round 
the  projecting  part  of  the  viscus,  and  then  cut  this 
obstinate  portion  of  the  liver  off.  The  patient  re- 
covered. 

From  a  reference  to  the  relations  of  the  liver,  it 
will  be  readily  understood  that  an  hepatic  abscess  may 
open  into  the  pleura,  and  in  some  cases,  indeed,  the 
pus  from  the  liver  has  been  discharged  by  the  bronchi. 
Thus,  it  has  been  possible  for  a  patient  to  cough  up 
some  portion  of  his  liver,  although,  of  course,  in  a  very 
disintegrated  and  minute  form.  Hepatic  abscess  may 


Chap.  XVI!.] 


ABDOMINAL   VJSCERA. 


355 


Fig.  33.  —View  of  some  of  the  Abdominal  Viscera  from  behind 

(Rudiuger). 

,  Thoracic  aorta;  b,  (Esophagus  ;  c,  common  carotid  artery  and  internal  jugular 
vein  ;  <{,  root  of  ri«ht  lung  ;  e,  inferior  vena  cava  ;  /,  tploen ;  <i,  stomach,  and 
to  its  riirht  t  lie  liver ;  h,  pancreas  ;  i,  descending  part  of  duodenum  (opened); 
j,  superior  inesenteric.  vein  joined  by  splenic  above ;  fc,  asccndinK  colon  ;  I,  do. 
accnding  colon ;  in,  sujtrior  hiemorrhoidal  vein  joining  inferior  mesenteric, 


356  SURGICAL  APPLIED  ANATOMY,  cchap.  xvn. 

also  open  into  either  the  duodenum  or  the  transverse 
colon,  or  even  into  the  stomach  or  the  right  kidney. 
The  liver  is  very  frequently  the  seat  of  the  secondary 
abscess  of  pyaemia,  and,  according  to  Mr.  Bryant's 
statistics,  abscesses  in  this  viscus  are  more  common 
after  injuries  to  the  head  than  after  injuries  elsewhere. 
They  are  rare  in  pysemia  following  affections  of  the 
urinary  organs,  and  are  equally  rare  in  the  pytemia 
after  burns.  The  liver  is  more  often  the  seat  of 
hydatid  cyst  than  are  all  the  viscera  taken  together. 
The  cyst  may  discharge  itself  externally,  or  into  the 
pleural  or  peritoneal  cavities,  or  into  any  adjacent  part 
of  the  intestine. 

The  ga.II  bladder  and  the  bile  duct  have  been 
ruptured  alone  without  rupture  of  the  liver.  The 
injury  is  rapidly  fatal,  owing  to  the  escape  of  bile  into 
the  peritoneal  cavity.  The  gall  bladder  is  often  occu- 
pied by  gall  stones.  These  concretions  are  composed 
mainly  of  cholesterin,  and  vary  in  size  from  a  hemp 
seed  to  a  hen's  egg.  Although  the  common  bile  duct 
is  only  about  three  lines  in  width,  it  is  remarkable 
to  note  what  comparatively  large  stones  have  been 
passed  along  it.  The  largest  stones  are  passed  direct 
into  the  bowel  through  a  nstulous  tract  that  has  been 
established  between  the  gall  bladder  and  the  intestine. 
Gall  stones  have  suppurated  out  through  the  anterior 
belly  wall,  and  have  been  removed  from  abscesses  in 
the  parietes.  Thus  Dr.  Burney  Yeo  reports  a  case 
where  more  than  one  hundred  gall  stones  were  dis- 
charged through  a  spontaneous  fistula  in  the  hypo- 
gastric  region,  five  inches  below  the  umbilicus.  In 
cases  where  the  bile  duct  is  occluded  by  gall  stones, 
or  by  other  causes,  the  gall  bladder  may  become  enor- 
mously distended,  and  may  form  a  tumour  extending 
some  way  beyond  the  umbilicus.  So  large  a  tumour  has 
been  formed  that  the  mass  has  been  mistaken  for  an 
ovarian  cyst  The  gall  bladder  as  it  enlarges  tends  to 


chap,  xvii.]  THE  SPLEEN.  357 

follow  a  line  extending  from  the  tip  of  the  right  tenth 
cartilage  across  the  median  line  of  the  abdomen  below 
the  umbilicus.  For  the  relief  'of  this  condition, 
cholecystotomy,  or  incision  into  the  gall  bladder,  has 
been  performed.  In  this  operation  the  incision  or 
puncture  is  made  over  the  most  prominent  part  of  the 
tumour.  Impacted  gall  stones  have  been  removed 
entire  from  the  bile  duct  through  an  incision  so  made, 
or  the  stone  has  been  crushed  in  situ  and  extracted  in 
fragments. 

In  cholecystectomy  the  whole  of  the  gall  bladder  is 
excised  and  the  cystic  duct  closed.  The  bile  finds  its 
way  into  the  intestine  direct  through  the  common 
duct. 

In  cholecystenterostomy  a  fistula  is  established 
between  the  gall  bladder  and  the  intestine.  The 
operation  is  carried  out  in  cases  in  which  there  is  an 
insuperable  obstruction  in  the  common  duct. 

THE  SPLEEN. 

.  In  front. 

Stomach. 
Splenic  flexure  of  colon. 


Outer  side. 
Diaphragm. 

9th  to  llth  ribs  between 
axillary  lines. 


Spleen. 


Inner  side. 

Stomach. 

Pancreas. 

L.  kidney  and  capsule. 


Behind. 
Diaphragm. 


The  spleen. — The  spleen  most  closely  approaches 
the  surface  in  the  parts  covered  by  the  tenth  and 
eleventh  ribs.  Above  this  it  is  entirely  overlapped 
by  the  edge  of  the  lung.  It  is  in  all  parts  separated 
from  the  parietes  by  the  diaphragm.  "  It  lies  very 
obliquely,  its  long  axis  coinciding  almost  exactly  with 
the  line  of  the  tenth  rib.  Its  highest  and  lowest 
points  are  on  a  level,  respectively,  with  the  ninth 


353 


SURGICAL  APPLIED  ANATOMY.  [Chap. xvn. 


dorsal  and  first  lumbar  spines  ;  its  inner  end  is  distant 
about  an  inch  and  a  half  from  the  median  plane  of  the 
body,  and  its  oiiter  end  about  reaches  the  mid-axillary 
line"  (Quain)  (Figs.  31,  33,  and  34).  It  possesses 


•-  c 


Fig  34  —Horizontal  Section  through  Upper  part  of  Ahdomen. 
(BUdinger.) 

a  Liver  •  6  stomach  ;  c,  transverse  colon  ;  d,  spleen :  «,  kidneys  ;  f,  pancrea 
g,  inferior  vena  cava  ;  ft,  aorta  with  thoracic  duct  behind  it. 


three  surfaces,  gastric,  renal,  and  phrenic,  well  shown 
in  Fig.  34. 

Injuries. — Although  extremely  friable  in  structure, 
the  normal  spleen  is  not  very  frequently  raptured. 
Its  connections,  indeed,  tend  to  minimise  the  effects 
of  concussions  and  contusions.  It  is  swung  up  by  the 
peritoneum,  rests  upon  the  elastic  costo-colic  fold,  and 
is  protected  by  the  stomach  and  lungs  to  a  considerable 
extent.  When  the  spleen,  however,  is  enlarged,  it  is 
very  readily  ruptured,  and  often  by  quite  insignificant 
violence.  Thus,  several  cases  have  been  recorded  of 
rupture  of  an  enlarged  spleen  by  muscular  violence. 


Chap,  xvii]  THE  SPLEEN.  359 

For  instance,  a  woman  ruptured  her  spleen  in  an 
attempt  to  save  herself  from  falling,  and  another  in 
springing  aside  to  avoid  a  blow.  The  patients  in  each 
instance  were  natives  of  India,  and  the  latter  case 
gave  rise  to  a  charge  of  homicide.  The  spleen  being 
extremely  vascular,  it  follows  that  ruptures  of  the 
viscus  are  usually,  but  not  necessarily,  fatal  from 
haemorrhage.  It  is  well  to  note,  in  connection  with 
this  matter,  that  the  spleen  contains  most  blood 
during  digestion.  A  case  is  reported,  however,  of  a 
boy  who  met  with  an  accident  just  after  dinner,  and 
who  managed  to  walk  some  distance,  although  his 
spleen,  as  the  autopsy  revealed,  was  separated  into 
three  portions.  He  lived  some  days.  In  severe 
fractures  of  the  ninth,  tenth,  and  eleventh  ribs  the 
spleen  may  be  damaged  and  lacerated. 

The  capsule  of  the  spleen  contains  muscular  tissue, 
and  must  possess  some  contractile  power.  This  fact 
may  serve  to  explain  cases  of  recovery  from  limited 
wounds  of  the  organ,  such  as  small  gunshot  wounds. 
In  such  lesions  the  capsule  may  contract  and  greatly 
narrow  the  hole  in  the  viscus,  while  the  track  of  the 
bullet  or  knife  may  become  filled  with  blood-clot,  and 
the  bleeding  thus  be  stayed. 

The  spleen  may  be  greatly  enlarged  in  certain 
diseased  conditions.  The  hypertrophied  spleen  may 
attain  such  dimensions  as  to  fill  nearly  the  whole 
abdomen,  and  in  one  case  a  cystic  tumour  so  com- 
pletely occupied  both  iliac  fossae  that  it  was  mistaken 
for  an  ovarian  cyst,  and  the  operation  for  ovariotomy 
was  commenced.  It  is  said  that  the  enlarged  spleen, 
in  its  earlier  stages,  encroaches  upon  the  thoracic 
cavity  relatively  more  in  the  child  than  in  the  adult. 
This  is  explained  by  the  statement  that  the  costo-colic 
fold,  upon  which  the  spleen  rests,  is  much  more 
resisting  in  the  young  than  it  is  in  those  of  more 
mature  age. 


360  SURGICAL  APPLIED  ANATOMY.  [Chap,  xvn 

Extirpation  of  the  spleen  has  been  very 
successful  in  cases  of  abdominal  wounds  with  pro- 
trusion of  the  viscus.  It  has  also  been  performed 
with  good  results  in  many  cases  of  hypertrophied 
spleen.  The  operation  is  not  considered  justifiable  in 
cases  of  lukfemic  enlargement  of  the  organ,  it  having 
proved  invariably  fatal  in  such  instances.  In  cases  of 
wounds  with  protrusion,  the  spleen  is,  of  course,  re- 
moved through  the  wound.  In  other  instances  the 
incision  is  usually  made  in  the  middle  line  the  most 
convenient  being  one  so  arranged  that  the  umbilicus 
corresponds  to  the  centre  of  the  cut.  Some  surgeons 
prefer  an  incision  along  the  outer  edge  of  the  left 
rectus  muscle.  The  viscus  is  then  slowly  pressed  out 
of  the  wound.  The  great  difficulty  is  with  the  gastro- 
splenic  omentum,  which  has  to  be  divided  and  its 
vessels  secured.  In  drawing  out  the  spleen  there  is 
much  risk  of  tearing  the  splenic  vessels,  especially  the 
vein.  Special  care  has  to  be  taken  to  avoid  damage 
to  the  pancreas. 

The  pancreas  lies  behind  the  stomach,  in  front 
of  the  first  and  second  lumbar  vertebrse.  It  crosses 
the  middle  line  on  a  level  with  a  point  about  three 
inches  above  the  umbilicus.  In  emaciated  subjects, 
and  when  the  stomach  and  colon  are  empty,  it  may 
sometimes  be  felt  on  deep  pressure.  It  is  in  relation 
with  many  most  important  structures,  but  presents 
but  little  surgical  interest  (Figs.  33  and  34).  It  has, 
I  believe,  never  been  ruptured  alone,  and  it  could 
scarcely  be  wounded  without  the  wound  implicating 
other  and  more  important  viscera.  It  has  been  found 
herniated  in  some  very  rare  cases  of  diaphragmatic 
hernia,  but  never  alone. 

It  may  become  invaginated  into  the  intestine,  and 
portions  of  the  gland  have  sloughed  off  and  been 
passed  in  the  stools.  In  resections  of  the  pylorus 
and  spleen  it  is  undesirable  that  a  ligature  be  placed 


chap,  xvii.]  THE  KIDNEY.  361 

on  any  part  of  the  pancreas  during  the  operation. 
There  are  two  reasons  for  this  precaution  :  "  First,  we 
know  that  after  ligature  of  the  parotid  (a  gland  of  like 
character  to  the  pancreas)  great  swelling  and  numer- 
ous small  abscesses  not  infrequently  form,  leading 
to  necrosis  of  portion  of  the  gland  ;  secondly,  there  is 
some  fear  that  (in  pyloric  resections)  the  secretion 
escaping  from  the  pancreas  may  dissolve  the  cicatrix 
of  the  stomach  by  its  peptonising  properties  "  (Billroth). 

The  common  bile  duct  is  covered  by,  or  included 
in,  the  head  of  the  pancreas.  It  thus  happens  that 
in  carcinoma  of  this  part  of  the  gland  the  duct  may 
become  entirely  occluded  and  jaundice  result.  Or  the 
duodenum  and  even  the  colon  may  be  more  or  less 
obstructed  by  pressure,  or  the  neighbouring  vessels  be 
closed. 

Certain  remarkable  cysts  are  sometimes  developed 
in  the  pancreas.  They  may  attain  great  size  and 
nearly  fill  the  abdomen.  Their  contents  consist 
mainly  of  altered  pancreatic  secretion,  and  when  the 
cyst  has  been  opened  the  escaped  fluid  is  apt  to 
exercise  a  digestive  action  on  the  skin. 

THE  KIDNEY. 

In  front. 

Right.  Left. 

Under  surface  of  liver.  Pundus  of  stomach. 

Second  part  of  duodenum.    Com-  Descending  colon, 

mencement  of  transverse  colon.  Pancreas. 
Ascending  colon. 

Externally. 
(On  left  side)  Spleen. 

Behind. 

Lower  part  of  arch  of  diaphragm. 
Quadratus  Iinnborum     Psoas. 

The  kidneys  are  deeply  placed,  and  cannot  be  felt 
and  distinctly  identified  when  normal.  They  are 


362  SURGICAL  APPLIED  ANATOMY,  [Chap.  xvn. 

most  accessible  to  pressure  at  the  outer  edge  of  the 
erector  spin?e,  just  below  the  last  rib.  The  right 
kidney  lies  nearly  three-quarters  of  an  inch  lower 
down  than  does  the  left ;  but  even  the  lower  end  of 
the  right  gland  only  just  reaches  to  the  level  of  the 
umbilicus.  The  upper  end  of  the  left  kidney  is  on  a  level 
with  the  eleventh  dorsal  spine  behind,  the  right  being  a 
little  lower  (Figs.  30  and  31).  The  inferior  extremity 
of  the  left  gland  is  about  one  and  five-eights  inches  from 
the  iliac  crest,  that  of  the  right  about  one  and  a 
quarter  inches.  The  kidney  lies  a  little  lower  in  the 
female  than  in  the  male.  In  many  instances  in  the 
female  its  lower  end  reaches  the  iliac  crest,  and  may 
even  go  below  it.  Such  positions  are  much  less 
common  in  the  male.  A  vertical  line  carried  upwards 
from  the  middle  of  Poupart's  ligament  has  one-third 
of  the  kidney  to  its  outer  side  and  two-thirds  to  its 
inner  side.  The  hilum  lies  about  two  inches  from  the 
middle  line,  and  is  opposite  to  the  gap  between  the 
first  and  second  lumbar  spines.  The  kidney  has  been 
reached  by  the  finger  when  the  entire  hand  has  been 
introduced  into  the  rectum,  but  the  procedure  has 
failed  to  prove  of  much  use  in  diagnosis. 

The  anterior  surface  is  but  slightly  covered  by 
peritonenin,  being  only  in  contact  with  that  membrane 
in  such  parts  as  are  not  in  relation  with  the  cellular 
tissue  at  the  back  of  the  colon  and  at  the  back  of  the 
duodenum  or  pancreas.  The  external  border  is  more 
closely  in  connection  with  the  peritoneum,  while  the 
posterior  surface  is  quite  devoid  of  that  membrane 
(Figs.  34  and  35).  Crossing  the  posterior  surface  of 
the  kidney  obliquely  from  above  downwards  and  out- 
wards are  branches  of  the  last  dorsal  nerve  and  of  the 
first  lumbar  artery,  together  with  the  ilio-hypogastric 
and  ilio- inguinal  nerves.  Rupture  of  the  kidney  is 
more  often  recovered  from  than  is  a  like  lesion  of 
any  other  of  the  more  commonly  injured  abdominal 


363 


•Fig.  35.— View  of  the  Kidneys,  etc.,  from  beliiud  (Riidiuger). 

a.  Pharynx;  ft,  innominate  artery ;  c,  subclavian  artery ;  d,  oesophagus,  with  the 
»  aorta  and  thoracic  duct  on  one  side  and  tbe  azygos  vein  on  tlie  other;  «, 
lungs  ;  /.diaphragm :  g,  kidney ;  ft,  on  peritoneum,  points  to  spermatic  vessels 
crossed  by  ureter ;  i,  <>s  innominatum  above  gacro-iliac-synchondrosis ;  j, 
psoas :  fc,  glutens  raediiis ;  {,  gluteug  maximug ;  TO,  rectum  and  sup.  haemorr- 
noidal  artery. 


364  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvn. 

viscera.  This  depends  upon  its  extensive  non- 
peritoneal  surface,  whereby  the  extravasation  of  blood 
and  urine  that  follows  the  accident  is  very  often 
entirely  extraperitoneaL  The  gland  may  he  readily 
wounded  from  behind  or  from  the  loin,  without  the 
peritoneum  being  injured.  When  the  spine  is  much 
bent  forwards,  the  kidney  lies  in  the  angle  of  the 
bend,  at  a  part  where  the  flexion  of  the  column  is 
the  most  acute.  In  extreme  flexion,  therefore,  of  the 
spine,  it  may  be  squeezed  between  the  ilium  and  the 
lower  ribs.  Thus,  hsematuria  is  not  uncommon  after 
injuries  to  the  back  associated  with  extreme  bending 
of  the  spine  forwards,  as  when  a  heavy  weight  falls 
upon  the  bowed  shoulders. 

The  kidney  is  embedded  in  a  large  quantity  of 
loose  fatty  tissue,  and  suppuration  extending  in  this 
tissue  constitutes  a  perinepkritic  abscess.  Such  an 
abscess  may  be  either  due  to  disease  of  the  kidney 
itself,  to  affections  of  the  adjacent  parts  (spine, 
colon,  etc.),  or  to  injuries.  The  pus  is  at  first  in  front 
of  the  quadratus  lurnborum,  and  then  usually  makes 
its  way  through  that  muscle  or  through  the  lumbar 
fascia.  It  then  presents  itself  at  the  outer  edge 
of  the  erector  spinse,  having  passed  between  the 
adjacent  borders  of  the  external  oblique  and 
latissimus  dorsi  muscles.  It  may,  however,  spread 
into  the  iliac  fossa,  or  extend  into  the  pelvis 
along  the  loose  connective  tissue  behind  the 
descending  colon  and  rectum,  or  open  into  the  colon 
or  blad'Jer,  or  even  into  the  lung.  Most  rarely  of  all 
does  it  perforate  the  peritoneum.  Renal  abscess 
usually  opens  upon  the  non-peritoneal  surface  of  the 
gland.  It  may  open  into  the  adjacent  colon.  In  one 
case  a  renal  abscess,  due  to  stone,  made  its  way  from 
the  right  kidney  into  the  pyloric  end  of  the  stomach, 
so  that  a  communication  was  established  between 
those  two  organs.  The  perirenal  fat  is  of  much 


chap,  xvii.]  THE  KIDNEY.  365 

surgical  importance,  as  its  laxity  permits  of  a  ready 
enucleation  of  the  organ.  It  is  more  abundant  behind 
than  in  front.  When  this  tissue  has  been  destroyed 
or  modified  by  inflammation,  the  kidney  becomes 
fixed,  and  its  removal  a  matter  of  great  difficulty. 
Movable  kidney. — The  kidney  is  fixed  in  position 
mainly  by  the  tension  of  the  peritoneum  that  passes 
over  it,  and  that  is  connected  with  the  fatty  tissue 
supporting  the  gland.  If  this  fatty  tissue  be  absorbed 
for  any  reason,  the  kidney  can  be  readily  moved  about 
and  displaced  in  the  subserous  tissue  ;  the  peritoneum 
at  the  same  time  becomes  lax,  and  the  gland  by  its 
own  weight  can  drag  still  further  upon  it.  Moreover, 
a  laxity  of  the  peritoneum  from  any  cause  may  loosen 
the  firm  connections  of  the  kidney,  and  allow  the 
organ  to  become  more  movable.  Thus,  the  movable 
kidney  is  often  met  with  in  badly  nourished  subjects, 
and  especially  in  those  who  have  become  emaciated 
by  disease.  It  is  far  more  common  in  women  than 
in  men.  In  the  former  sex  the  influence  of 
pregnancy  appears  to  have  especial  effect,  acting, 
probably,  by  dragging  upon  the  peritoneum,  and  by 
loosening  its  connections,  as  well  as  by  inducing, 
after  delivery,  a  general  laxity  of  the  abdominal 
walls.  The  movable  kidney  can,  of  course,  only  be 
moved  within  a  segment  of  a  circle  whose  radius 
corresponds  to  the  length  of  the  renal  vessels,  and 
its  displacement  is  seldom  considerable.  There  is  a 
congenital  form  of  movable  kidney  where  the  gland 
is  suspended  in  a  peritoneal  fold  of  its  own,  the 
meso-nephron,  and  where  the  renal  vessels  are  of 
undue  length.  Such  a  kidney  may  be  found  near 
the  anterior  abdominal  wall. 

Abnormalities  of  the  kidney.— One,  or  less 
frequently,  both  kidneys  may  be  misplaced.  The 
left  is  more  often  out  of  place  than  the  right,  and 
may  be  found  over  the  sacro-iliac  synchoiidrosis,  or 


366  SURGICAL  APPLIED  ANATOMY.  [Chap. xvn. 

the  promontory  of  the  sacrum,  or  be  discovered  in 
the  iliac  fossa  or  pelvis.  The  misplaced  kidney 
is  often  misshaped.  The  kidney  may  exhibit  a  more 
or  less  extreme  degree  of  tabulation.  The  ureter 
may  be  double. 

The  two  kidneys  may  be  fused.  "  The  lowest 
degree  of  fusion  is  seen  in  the  horse-shoe  kidney. 
The  two  kidneys  are  united  at  their  inferior  portions 
by  a  flat,  riband-like,  or  rounded  bridge  of  tissue, 
which  crosses  the  vertebral  column.  In  the  higher 
degrees  the  two  lateral  portions  approach  one  another 
more  and  more  until  they  reach  the  highest  degree, 
in  which  a  single  disc- like  kidney,  lying  in  the 
median  line,  and  provided  with  a  double  or  single 
calyx,  represents  complete  fusion"  (Rokitansky). 
When  the  two  kidneys  are  united  by  a  web  of 
connective  tissue,  the  condition  is  no  bar  to  opera- 
tion. There  may  be  an  entire  absence  of  one 
kidney.  The  single  kidney  may  be  lateral  or  median 
in  position.  Henry  Morris  gives  the  following 
estimate  of  the  frequency  of  these  abnormal  con- 
ditions. Congenital  absence  or  extreme  atrophy  of  one 
kidney  may  be  expected  in  about  one  in  4,000  cases, 
the  horse-shoe  kidney  in  one  in  1,600,  and  the  single 
fused  kidney  in  one  in  8,000  cases. 

Operations  on  the  kidney.— (1)  Nephrotomy. 
Incision  into  the  kidney  for  exploration,  or  the 
evacuation  of  pus.  (2)  Nephro-lithotomy.  Incision 
into  the  gland  for  the  removal  of  a  calculus.  (3) 
Nephrectomy.  Removal  of  the  entire  organ.  (4) 
Nephroraphy.  The  operation  of  securing  a  movable 
kidney  in  its  normal  position.  In  the  first,  second, 
and  fourth  operations  the  kidney  is  reached  through 
the  loin  by  an  oblique  incision,  such  as  is  used  in 
colotomy  (page  349),  the  cut,  however,  being  carried 
a  little  farther  backwards.  In  nephrectomy  a  like 
incision  may  be  used.  The  cut  is  carried  backwards 


Chap,  xvii.]  THE  KIDNEY.  367 

about  one  inch  over  the  erector  spinee,  and  a  part 
of  the  quadratus  lumborurn  will  probably  have  to  be 
divided.  The  periuepliritic  tissue  is  opened  up,  and 
the  gland  enucleated  from  the  capsule  of  fat  in  which 
it  lies.  In  some  instances  the  last  rib  has  been 
resected  to  obtain  more  space  for  the  operation. 
This  can  be  done  without  risk  to  the  pleura.  In 
one  case  the  twelfth  rib  was  rudimentary,  and  the 
eleventh  rib  was  removed  under  the  impression  that 
it  was  the  twelfth.  The  pleura  was  opened  and  death 
ensued. 

When  the  kidney  is  free  from  its  fatty  capsule, 
the  vessels  at  the  hilum  are  secured  en  masse  by  a 
ligature.  They  constitute  a  surgical  pedicle  of  the 
kidney.  At  the  hilum  the  vein  lies  in  front,  the  artery 
and  its  branches  next,  and  the  ureter  behind  and 
towards  the  lower  part.  The  artery  is  about  the  size 
of  the  brachial,  and  usually  divides  into  four,  five,  or 
six  branches  before  it  reaches  the  kidney.  This  fact 
must  be  borne  in  mind  if  the  structures  at  the  hilum 
are  separately  secured.  The  vein  also  is  represented 
at  the  hilum  by  three  or  four  branches.  The  renal 
artery  may  be  represented  by  two,  three,  four,  or  even 
live  branches.  Some  may  enter  the  upper  end  of  the 
kidney  or  its  anterior  surface.  In  removing  large 
renal  gi'owths  an  abdominal  incision  is  advised,  the 
cut  being  made  either  along  the  corresponding  semi- 
lunar  line,  and  on  a  level  with  the  diseased  mass, 
and  in  the  linea  alba.  The  abdominal  operation  of 
course  involves  an  opening  into  the  peritoneal  cavity, 
but  it  has  the  advantages  of  greater  ease  and  rapidity 
in  performance. 

The  ureters  are  strong  tubes  about  fifteen  inches 
long,  with  thick  muscular  walls,  and  are  placed 
entirely  behind  the  peritoneum.  The  average  width 
is  that  of  a  goose-quill.  The  ureter  rests  from  above 
downwards  upon  (1)  the  psoas  muscle  and  the  genito- 


368  SURGICAL  Ar PLIED  AXATOMY.  [Chap.xvn. 

crural  nerve ;  (2)  the  common  iliac  vessels  on  the  left 
side,  and  the  external  iliac  vessels  on  the  right ;  (3) 
it  then  enters  the  posterior  false  ligament  of  the 
bladder,  and  so  reaches  the  bladder  wall.  The 
narrowest  part  of  the  tube  is  the  portion  within  the 
bladder  walls,  and  when  renal  calculi  pass  along  the 
ureter  they  are  often  arrested  at  this  point.  The 
ureters  permit  of  great  distension,  and  in  certain 
cases  of  gradual  dilatation  they  have  attained  a  width 
equal  to  that  of  the  thumb  and  even  of  the  small 
intestine.  Several  cases  are  recorded  of  rupture  of 
the  ureter  from  external  violence.  When  such  an 
accident  occurs  a  large  urinary  collection  usually 
forms  behind  the  peritoneum,  which,  leading  to 
suppuration,  will  produce  a  fluctuating  tumour 
beneath  the  parietes. 

After  the  vessels  have  been  tied,  the  ureter  is 
isolated  and  sequred  on  a  level  with  the  lower  end  of 
the  kidney,  the  ureter  begins  to  expand  into  a  funnel- 
shaped  cavity — the  pelvis.  This  in  turn  divides  into 
the  calyces.  In  the  pelvis  or  calyces  calculi  are 
frequently  lodged.  The  calyces  are  too  narrow  to 
admit  an  exploring  finger. 

The  nerve  supply  of  the  abdominal  viscera. 
— Some  account  has  already  been  given  of  these 
nerves  and  their  communications  (page  298).  The 
abdominal  viscera  are  mainly  supplied  by  the 
sympathetic  system  through  a  series  of  remarkable 
plexuses.  The  most  important  of  these  is  the  solar, 
from  which  is  more  or  less  directly  derived  the  nerve 
supply  of  the  stomach,  liver,  spleen,  kidneys, 
suprarenal  capsules,  pancreas,  and  such  parts  of  the 
intestine  .as  are  in  connection  with  the  superior 
mesenteric  artery.  The  solar  plexus  and  its 
appendages  receive  the  splanchnic  nerves  and  some 
branches  from  the  vagus,  while  communications  from 
the  phrenic  go  to  the  hepatic  and  suprarenal  plexuses. 


chap,  xvii.]  ABDOMINAL  NERVES.  369 

It  may  be  well  understood  that  an  impression  brought 
to  bear  upon  nerve  centres  of  such  extent  and  with 
such  important  relations  would  produce  considerable 
effects.  These  effects  we  see  in  the  profound  collapse, 
vomiting,  and  other  grave  symptoms  that  attend 
severe  injuries  to  the  viscera,  and  especially  to  those 
that  are  the  most  directly  associated  with  these  large 
centres.  The  descending  colon  and  sigmoid  .flexure 
are  supplied  by  the  inferior  mesenteric  plexus,  a  cord 
that  has  but  an  indirect  connection  with  the  solar 
plexus  ;  and  this  fact  may  serve  to  account  for  the 
less  serious  symptoms  often  seen  in  strangulation  of 
the  colon  when  compared  with  a  like  lesion  of  the 
small  gut.  The  upper  part  of  the  colon,  although 
supplied  by  the  superior  mesenteric  plexus,  is  only 
supplied  by  that  part  of  it  that  is  most  remote  from 
the  great  centres,  and  it  is.  a  conspicuous  fact  that 
the  nearer  the  lesion  is  to  the  stomach,  the  graver, 
other  things  being  equal,  are  the  nervous  phenomena 
produced.  It  would  appear  that  some  lesion  of  these 
nerve  plexuses  is  sometimes  active  in  producing  a 
remarkable  pigmentation  of  the  skin.  This  is  seen 
in  Addison's  disease,  a  disease  marked  by  a  general 
bronzing  of  the  surface,  and  usually  associated  with 
some  disintegration  of  the  suprarenal  capsules.  The 
very  direct  relation  of  these  bodies  to  the  solar  plexus 
is  well  known.  In  pregnancy  also,  in  abdominal 
tuberculosis,  in  cancer  of  the  stomach,  and  in  liver 
diseases,  a  pigmentation  of  the  face  is  sometimes  seen, 
that  may  in  such  instances  be  probably  ascribed  to  a 
disturbance  of  the  great  abdominal  nerve  centres. 

In  some  diseases  of  the  liver  and  stomach  "  sympa- 
thetic "  pains  are  complained  of  between  the  shoulders 
or  about  the  inferior  angles  of  the  scapulae.  These 
parts  are  supplied  with  sensation  by  the  fourth,  fifth, 
and  sixth  dorsal  nerves.  The  great  splanchnic  cord 
can  probably  explain  the  peculiar  seat  of  these  pains, 
y— 4 


3 jo  SURGICAL  APPLIED  ANATOMY.  iChao  xvu 

since  it  is  connected  on  the  one  hand  with  the  plexuses 
that  supply  the  stomach  and  liver,  and  on  the  other 
hand  with  these  very  dorsal  nerves  that  are  distributed 
about  the  lower  interscapular  space.  Much  discussion 
has  taken  place  as  to  the  cause  of  the  "  shoulder  tip  " 
pain  often  complained  of  in  liver  ailments.  Some 
imagine  that  the  pain  is  conducted  along  the  hepatic 
plexus .  to  the  vagus,  thence  to  the  spinal  accessory, 
and  so  to  the  point  of  the  shoulder.  Others  trace  it 
from  the  liver  plexus  to  the  phrenic,  thence  to  the  third 
and  fourth  cervical  nerves  (from  whence  the  phrenic 
is  in  great  part  derived),  and  finally  to  those  branches 
of  these  cervical  trunks  that  go  to  the  shoulder  tip 
(the  acromial  brandies). 

There  would  seem  to  be  but  little  connection 
between  a  disease  in  the  sigmoid  flexure  and  a  pain  in 
the  knee,  yet  in  cases  of  .cancer  of  the  flexure,  and  in 
instances  where  it  has  been  distended  with  faeces,  such 
a  pain  has  been  complained  of.  The  pain  is  conveyed 
along  the  obturator  nerve,  which  lies  beneath  the 
sigmoid  flexure,  and  could  be  readily  pressed  upon  by 
the  gut  when  diseased. 

The  blood-vessels  of  the  abdomen. — Some 
of  the  visceral  branches  of  the  abdominal  aorta  are  of 
large  size,  and  would  bleed  very  copiously  if  wounded. 
Thus,  the  cffiliac  axis,  and  the  superior  mesenteric 
artery,  are  as  large  as  the  common  carotid  ;  the  splenic, 
hepatic,  and  renal  vessels  are  about  the  size  of  the 
brachial ;  while  the  largest  part  of  the  inferior  inesen- 
teric  trunk  has  dimensions  equal  to  those  of  the  ulnar 
artery.  Aneurisms  of  the  aorta  are  especially  apt  to 
occur  at  the  cceliac  axis,  that  being  a  point  where  a 
number  of  large  branches  are  abruptly  given  off,  and 
where  the  course  of  the  circulation  undergoes  in  con- 
sequence a  sudden  deviation. 

When  it  is  remembered  that  the  lumbar  glands 
lie  about  the  vena  cava  and  iliac  veins,  it  will  be 


chap,  xvii.]    ABDOMINAL  BLOOD-VESSELS.  371 

understood  that  great  enlargement  of  those  bodies 
may  cause  oedema  from  pressure. 

A  number  of  minute  but  most  important  anasto- 
moses exist  between  some  of  the  visceral  branches 
of  the  abdominal  aorta  and  certain  of  the  vessels 
supplied  to  the  abdominal  parietes.  These  anasto- 
moses are  situated  behind  the  peritoneum,  and 
mostly  concern  such  viscera  as  have  a  fair  surface 
uncovered  by  that  membrane.  The  visceral  branches 
that  join  the  anastomoses  are  derived  from  the  hepatic, 
renal,  and  suprarenal  arteries,  and  from  the  vessels 
supplying  the  lower  part  of  the  duodenum,  the  pan- 
creas, the  caecum,  and  the  ascending  and  descending 
segments  of  the  colon.  The  parietal  vessels  joining 
with  the  above  are  derived  from  the  phrenic,  lumbar, 
ilio-lumbar,  lower  intercostal,  epigastric,  and  circum- 
flex iliac  trunks.  In  a  case  detailed  by  Professor 
Chiene  (Journ.  Anat.  and  Phys.,  vol.  iii.)  the  coeliac 
axis  and  mesenteric  vessels  were  plugged,  but  blood 
in  sufficient  amount  to  supply  the  viscera  had  reached 
the  branches  of  these  arteries  through  their  parietal 
communications.  The  anastomosis  gives  an  anatomical 
demonstration  of  the  value  of  local  blood-lettings  and 
of  counter-irritants  in  inflammatory  affections  of 
certain  of  the  viscera,  and  also  a  scientific  basis  to  the 
ancient  practice  of  poulticing  the  loin  and  the  iliac 
region  in  nephritis  and  in  inflammation  about  the 
caecum. 

Cases  have  been  recorded  of  communications 
between  the  external  iliac  vein  and  the  portal  vein. 
These  have  generally  been  effected  by  the  deep 
epigastric  vein  joining  with  a  pervious  umbilical  vein 
in  the  vicinity  of  the  navel. 

Thoracic  duct.— Some  six  cases  of  wound  of 
this  duct  have  been  reported,  the  injury  being  usually 
a  stab.  In  each  case  lymph  and  chyle  in  large 
quantities  escaped  from  the  wound.  In  one  instance 


372  SURGICAL  APPLIED  AN  ATOMS,  [ciup.  xvm. 

^he  duct  is  said  to  have  been  injured  by  a  bullet 
that  entered  just  below  the  left  scapula,  since  from 
the  wound  in  the  integuments  large  quantities  of 
lymph  escaped  freely.  The  duct  has  been  found  to 
have  been  obliterated,  and  that,  too,  without  pro- 
ducing any  marked  symptoms  during  life. 


CHAPTER   XVIII. 

THE    PELVIS    AND    PERINEUM. 

THE  mechanism  of  the  pelvis.— Besides 
forming  a  cavity  for  certain  viscera,  a  support  for 
some  abdominal  organs,  and  a  point  for  the  attachment 
of  the  lower  limb,  and  of  many  muscles,  the  pelvis 
serves  to  transmit  the  weight  of  the  body  both  in  the 
standing  and  sitting  postures.  The  transmission  is 
effected  through  two  arches,  one  available  for  the 
erect  position,  the  other  for  the  posture  when  sitting. 
The  sacrum  which  supports  the  spinal  column  is  the 
centre  or  keystone  of  both  these  arches.  When  stand- 
ing, the  arch  is  represented  by  the  sacrum,  the  sacro- 
iliac  synchondroses,  the  ace  tabula,  and  the  masses  of 
bone  extending  between  the  two  last-named  points.  If 
all  other  parts  of  the  pelvis  were  to  be  cut  away  but 
these,  the  portions  left  would  still  be  able  to  support 
the  weight  of  the  body,  and  would  represent  in  its 
simplicity  the  arch  through  which  that  weight  is 
transmitted.  When  sitting  the  arch  is  represented  by 
the  sacrum,  the  sacro-iliac  synchondroses,  the  tubera 
ischii,  and  the  strong  masses  of  bone  that  extend 
between  the  two  last-named  parts.  Morris  terms 
these  two  arches  the  femoro-sacral  and  the  ischio- 
sacral.  On  examining  the  innominate  bone  it  will 


Chap,  xvi  ii.]  THE  P ELY  is.  373 

be  seen  that  its  thickest  and  strongest  parts  are  such 
as  are  situate  in  the  line  of  these.  "  When  very  con- 
siderable strength  is  requisite  in  an  arch,  it  is 
continued  into  a  ring  so  as  to  form  a  counter-arch,  or 
what  is  called  a  tie  is  made  to  connect  together  the 
ends  of  the  .arch,  and  thus  to  prevent  them  from 
starting  outwards.  By  these  means  a  portion  of  the 
superincumbent  weight  is  conveyed  to  the  centre  of 
the  counter-arch,  and  borne  in  what  is  called  the  sine 
of  the  arch.  The  body  and  horizontal  raaai  of  the 
pubes  form  the  tie  or  counter-arch  of  the  femoro-sacral, 
and  the  united  rami  of  the  pubes  and  ischium  the  tie 
of  the  ischio-sacral  arch.  Thus  the  ties  of  both  arches 
are  united  in  front  at  the  symphysis  pubis,  which,  like 
the  sacrum  or  keystone,  is  common  to  both  arches. 
....  This  explains  how  it  is  that  so  much  strain 
is  made  upon  the  symphysis  when  any  increased  weight 
has  to  be  supported  by  the  pelvis,  as  in  pregnancy  ; 
why  there  is  such  powerlessness,  with  inability  to 
stand  or  sit,  in  cases  in  which  this  joint  is  weakened 
or  diseased;  and  why  the  anterior  portion  of  the 
pelvis  yields  under  the  weight  of  the  body,  and 
becomes  deformed  in  rickets  and  mollities  ossium."  * 
The  pelvic  deformity  in  rickets,  it  may  be  here 
observed,  varies  greatly  according  to  the  age  at  which 
the  disease  sets  in,  and  the  usual  attitude  of  the  child 
when  it  becomes  affected.  The  deformity  sometimes 
produced  in  very  young  infants  has  been  ascribed 
to  muscular  contraction  (ilio-psoas,  erector  spinae, 
glutens  medius,  etc.).  In  the  rickety  pelvis,  par 
excellence,  the  two  acetabula  approach  one  another, 
the  anterior  part  of  the  pelvis  yields,  so  that  the 
symphysis  is  pushed  forward,  and  the  cavity  becomes 
greatly  narrowed  in  its  antero-posterior  diameter. 
In  severe  cases  the  anterior  arch  may  practically 

*  Henry  Morris  on  "The  Joints,"  p.  116,  where  a  most  valu- 
able account  of  the  mechanism  of  the  pelvis  will  be  found. 


374  SVRC.ICAL  APPLIED  ANATOMY. [Chap. xvni. 

collapse,  and  the  horizontal  rami  of  the  pubes  be  for 
some  little  way  parallel  to  one  another. 

In  the  erect  attitude  the  pelvis  is  so  inclined  that 
the  plane  of  the  brim  of  the  true  pelvis  forms  with 
the  horizon  an  angle  of  from  60°  to  65°  ;  the  base  of 
the  sacrum  is  about  3|-  inches  above  the  upper  border 
of  the  symphysis,  while  the  tip  of  the  coccyx  is  a  little 
higher  than  its  lower  border.  The  centre  of  gravity 
of  the  whole  body  (adult)  is  at  a  spot  just  ubuve  the 
sacro-lumbar  angle,  and  exactly  over  the  mid-point  of 
a  line  drawn  between  the  heads  of  the  femora.  The 
obliquity  of  the  pelvis  materially  assists  in  breaking 
shocks,  and  in  distributing  forces  applied  from  below 
throughout  the  pelvic  ring.  In  modifying  the  effect 
of  shocks,  also,  it  is  aided  by  the  arches  of  the  pelvis, 
and  by  the  buffer-like  discs  of  cartilage  at  the 
symphysis  and  sacro-iliac  joints. 

Fractures  of  the  pelvis. — From  what  has 
been  already  said,  it  may  be  surmised  that  the  weakest 
parts  of  the  pelvis  are  at  the  symphysis  and  the  sacro- 
iliac  joints.  The  bones  of  these  parts,  however,  are 
so  very  firmly  knit  together  by  powerful  ligaments 
that  it  is  very  rare  for  these  articulations  to  give  way, 
fracture  of  the  adjacent  bones  being  more  common. 
The  commonest  fracture  of  the  pelvis  is  in  the  weak 
counter  arch,  and  involves  the  rami  of  both  the  pubes 
and  the  ischiuni.  The  fracture  is  often  associated  with 
some  tearing  of  ligaments  about  the  sacro-iliac  synchon- 
drosis,  and  is  met  with  in  accidents  due  to  the  most 
varied  forms  of  violence.  This  last  remarkable  circum- 
stance is  thus  explained  by  Tillaux.  If  the  pelvis  be 
compressed  in  (a)  an  antero-posterior  direction,  the 
main  brunt  of  the  force  comes  upon  the  weak  counter 
arch,  which  fractures  from  direct  violence.  The  force 
continuing,  tends  to  push  asunder  the  two  iliac  bones, 
and  so  causes  rupture  of  the  anterior  ligaments  at  the 
sacro-iliac  joint.  If  the  force  be  applied  (6)  trans- 


chap,  xvin.]  THE  PELVIS.  375 

versely,  the  two  acetalmla  tend  to  be  pressed  towards 
one  another,  the  counter  arch  becomes  more  bent, 
and  ultimately  gives  way  by  indirect  violence.  The 
violence  continuing,  forces  the  two  ilia  towards  one 
another,  the  strain  then  falls  upon  the  sacro-iliac 
synchondrosis,  and  the  posterior  ligaments  of  that 
joint  are  apt  to  yield,  or  portions  of  the  bone  adjacent 
to  the  joint  are  torn  away.  In  cases  of  falls,  when 
the  patient  alights  upon  the  feet  or  ischial  tuberosities, 
it  can  be  understood  how  in  many  instances  the  main 
arches  will  escape  injury  owing  to  their  great  strength, 
while  the  counter  arch  becomes  fractured.  Any  part 
of  the  pelvis,  including  the  sacrum,  may  be  broken 
by  well-localised  direct  violence.  More  or  less  of  the 
iliac  crest,  the  anterior  superior  and  posterior  superior 
spines,  have  been  knocked  off.  The  first-named  part 
may  be  separated  as  an  epiphysis.  It  joins  the  bone 
at  about  the  twenty-fourth  year.  In  one  case  the 
anterior  inferior  spinous  process  was  torn  off  by  the 
rectus  muscle  during  the  act  of  running  a  race.  The 
os  innominatum  has  been  broken  into  its  three 
anatomical  portions.  This  accident  cannot  take  place 
after  about  the  seventeenth  year,  since  by  that  time 
the  Y-shaped  cartilage  is  usually  fully  ossified,  and 
the  three  elementary  bones  are  firmly  united.  Before 
such  consolidation  occurs  abscess  in  the  hip  joint  not 
very  infrequently  makes  its  way  through  the  cartilage 
into  the  pelvis.  The  acetabulum  has  been  fractured, 
and  the  head  of  the  femur  driven  through  its  thinnest 
part  into  the  pelvis.  In  fractures  of  the  pubes  and 
ischium  the  bladder  has  been  torn  by  the  sharp 
fragments.  In  one  case  a  loose  piece  of  bone  that 
had  been  driven  into  the  bladder  became  the  nucleus 
for  a  stone.  The  urethra  and  vagina  also  have  been 
lacerated,  or  seriously  compressed  by  the  displaced 
bones.  In  fractures  of  the  sacrum  the  rectum  has 
been  torn,  or  has  been  so  compressed  by  the  lower 


3?6  SUKCICAL    APPLIKD    A.VA  TOMY.  [Chap.  XVIlt. 

fragment  (which  is  almost  always  carried  forwai-ds) 
as  to  be  nearly  closed. 

Special  parts  of  the  pelvis.    Sympliysis.— 

Separation  of  the  bones  at  the  symphysis  without 
fracture  has  occurred  from  severe  violence.  Malgaigne 
reports  three  cases  where  the  separation  was  brought 
about  by  muscular  violence  only,  by  extreme  action 
of  the  adductor  muscles  of  the  two  sides.  The 
Sigaultean  operation  consisted  in  dividing  the  sym- 
physis pubis  in  cases  of  contracted  pelvis,  with  the 
idea  of  obtaining  more  room  during  labour,  and  of  so 
avoiding  Csesarian  section.  It  has  been  shown,  how- 
ever, that  to  gain  half  an  inch  in  the  aiit-ero-posterior 
diameter  the  bones  must  be  separated  to  the  extent 
of  two  inches.  Such  a  separation  involves  laceration 
of  the  sacro-iliac  ligaments,  and  more  or  less  damage 
to  the  attachments  of  the  pelvic  viscera. 

The  sacro-iliac  sycliondrosis  may  be  the  seat 
of  disease.  formally,  there  is  no  movement  at  this 
joint,  but  when  the  ligaments  are  softened  by  disease, 
and  eflusion  occurs  between  the  opposed  bones,  some 
movement  may  be  demonstrated.  As  this  joint  lies 
in  the  line  of  the  great  arches  of  the  pelvis,  it  follows 
that  when  inflamed  much  pain  is  felt  in  the  part, 
both  when  the  patient  is  standing  or  sitting.  When 
abscess  forms  it  tends  to  come  forwards,  owing  to  the 
fact  that  the  anterior  ligaments  are  less  dense  than 
the  posterior.  Having  reached  the  pelvic  aspect  of 
the  joint,  the  pus  may  occupy  the  iliac  fossa,  or  gain 
the  ilio-psoas  sheath.  Or  it  may  follow  the  lumbo- 
sacral  cord  and  great  sciatic  nerve  and  point  in  the 
thigh  behind  the  great  trochanter,  or  it  may  be 
guided  by  the  obturator  vessels  to  the  inner  side  of 
the  thyroid  foramen,  and  ultimately  appear  at  the 
inner  side  of  the  thigh.  The  abscess  may,  however, 
proceed  backwards,  and  point  over  the  posterior  aspect 
of  the  joint. 


Chap,  xvi 1 1.)  THE  PELVIS.  377 

The  nerve  relations  of  this  joint  are  important. 
It  is  supplied  by  the  superior  gluteal,  by  the  lumbo- 
sacral  cord  and  first  sacral  nerve,  and  by  the  first  and 
second  posterior  sacral  nerves  (Morris).  The  lumbo- 
sacral  cord  and  the  obturator  nerve  pass  over  the 
front  of  the  joint,  the  former  being  very  closely  con- 
nected with  the  articulation.  It  will  be  understood 
from  these  relations  that  in  sacro-iliac  disease  pain  is 
felt  over  the  sacral  region  (upper  sacral  nerves)  and 
in  the  buttock  (gluteal  nerve).  Much  pain  is  also 
often  complained  of  in  the  hip-  or  knee-joint,  and 
along  the  inner  part  of  the  thigh  (obturator  nerve). 
In  one  or  two  reported  cases  there  has  been  severe 
pain  in  the  calf  and  back  of  the  thigh,  with  painful 
twitchings  in  the  muscles  of  those  parts  (lumbo- 
sacral  cord  and  connection  with  great  sciatic  nerve). 
Dislocation  of  the  sacrum  at  this  joint  is  prevented  by 
the  remarkable  double-wedge-shaped  outline  of  the 
bone,  and  by  the  very  dense  ligaments  that  bind  it 
in  its  place.  The  thick  end  of  the  main  wedge  of  the 
sacrum  is  in  front,  and  therefore  the  strongest  liga- 
ments are  to  be  found  behind  the  bone,  as  if  to  pre- 
vent it  from  slipping  forwards,  or  from  becoming 
rotated  forwards  on  its  transverse  axis. 

Trendelenburg 's  operation. — In  order  to  bring  the 
two  pubic  bones  and  the  deficient  soft  parts  together 
in  ectopia  vesicae,  Trendelenburg  divides  the  sacro- 
iliac  synchondroses  on  either  side.  The  knife  is  made 
to  cut  the  posterior  sacro-iliac  ligaments,  the  inter- 
osseous  and  superior  ligaments,  and  the  interarticular 
cartilage.  The  operation,  which  has  been  very 
successful,  is  limited  to  children  between  the  ages  of 
two  and  five.  The  distance  between  the  anterior 
superior  iliac  spines  has — in  a  child  aged  two  and  a- 
half  years — been  lessened  two  inches  by  this  opera- 
tion. 

Spiiia  bi(i<!u.  —This  term   refers  to  certain  con- 


378  SURGICAL  APPLIED  <4Avtr0JifX.cChap.xvm. 

genital  malfoi'mations  of  tlie  vertebral  canal  associated 
with  the  protrusion  of  some  of  its  contents  in  the 
form  of  a  fluid  tumour.  The  malformation  usually 
consists  in  an  absence  of  the  neural  arches  and  spines 
of  certain  of  the  vertebrae,  and  the  tumour  therefore 
projects  posteriorly.  Spina  bifida  is  most  common  in 
the  lumbo  sacral  region,  the  neural  arches  of  the  last 
lumbar  and  of  all  the  sacral  vertebrae  being  absent. 
Next  in  frequency  it  is  found  limited  to  the  sacral 
region.  It  is  rare  elsewhere.  (1)  The  membranes 
may  protrude  alone  (spinal  meningocele).  (2)  The 
membranes  may  protrude  together  with  the  spinal 
cord  and  its  nerves  (meningo-myelocele).  (3)  The 
membranes  may  protrude  with  the  cord,  the  central 
canal  of  which  is  dilated,  so  as  to  form  a  sac  cavity 
(syringo-myelocele). 

The  meningo-myelocele  is  the  most  common  form. 
The  first-named  variety  is  rare,  the  last-named  very  rare. 
When  the  cord  occupies  the  sac  it  usually  adheres  to 
its  posterior  wall,  the  nerves  running  transversely 
across  the  sac  to  reach  the  intervertebral  foramina. 

As  may  be  expected,  spina  bifida  is  very  commonly 
associated  with  some  evidence  of  injury  to  the  nerves 
arising  from  the  lower  part  of  the  spinal  cord.  In  the 
majority  of  instances  certain  of  these  nerves  would 
appear  to  have  become  atrophied  through  pressure. 
In  some  cases  the  nerve  affection  takes  the  form  of  club- 
foot  of  a  severe  grade.  In  other  instances  there  is 
more  or  less  complete  paralysis  of  the  lower  limbs, 
bladder,  and  rectum. 

"  The  anatomy  of  spina  bifida  assumes  a  primary 
defect  of  development  of  the  mesoblast,  from  which 
the  structures  closing  in  the  vertebral  furrow  are  de- 
veloped. After  the  closure  of  the  neural  furrow  it 
would  appear  that  the  processes  of  mesoblast,  which 
subsequently  insinuate  themselves  between  the  primi- 
tive spinal  cord  and  its  overlying  epiblast,  ai'e  formed 


chap  xvi 1 1. j  THE  PELVIS.  379 

in  an  insufficient  degree  to  meet  and  combine  "  (Com- 
mittee of  the  Clinical  Society,  London,  1885). 

Sacro-coccygeal  tumours. — The  sacro-coccy- 
geal  region  is  very  often  the  seat  of  congenital  tumours, 
some  of  them  of  such  a  shape  as  to  form  "  human 
tails ; "  and  to  this  part  of  the  pelvis  has  also  been 
found  attached  a  third  lower  limb  leading  to  the 
condition  known  as  "  tripodism." 

Parasitic  foetuses  are  also  frequently  found  attached 
to  this  segment  of  the  spine.  In  many  of  the  instances 
of  attached  foetuses  the  two  individuals  have  been  joined 
together  at  this  part  of  the  column.  Some  of  the  sacro- 
coccygeal  tumours  contain  epithelial  cysts  and  fragments 
of  skin,  muscle,  nerve,  bone,  cartilage,  and  mucous  mem- 
brane. These  strange  masses  spring  from  the  anterior 
part  of  the  coccyx,  between  it  and  the  rectum.  By  some 
they  are  supposed  to  arise  from  Luschka's  gland,  by 
others  (Sutton)  from  the  structures  known  to  embryo- 
logists  as  the  post-anal  gut  and  the  neurenteric  passage. 

The  sacro-coccygcal  joint  may  be  dislocated 
or  diseased.  In  either  affection  great  pain  is  kept  up 
from  the  frequent  movement  of  the  part  by  the 
muscles  attached  to  the  coccyx  (the  glutens  maximus, 
coccygeus,  levator  ani,  and  sphincter).  In  the 
luxation  the  bone  may  project  into  the  rectum,  and 
thus  give  trouble.  The  joint  and  the  parts  about 
it  may  be  the  seat  of  such  severe  neuralgia  ("  coccygo- 
dynia  ")  as  to  require  excision  of  the  coccyx,  or  a  free 
division  of  the  structures  that  cover  it  behind.  The 
joint  and  the  fibrous  tissue  about  it  are  supplied  by 
the  following  nerves ;  the  posterior  divisions  of  the 
second,  third,  and  fourth  sacral,  and  the  anterior  and 
posterior  divisions  of  the  fifth  sacral  and  coccygeal. 

The  thinnest  parts  of  the  os  innominatum 
are  at  the  bottom  of  the  acetabulum,  and  in  the  hollow 
of  the  wing  of  the  ilium.  In  the  latter  situation  the 
bone  has  been  successfully  trephined  for  iliac  abscess. 


380          SURGICAL  APPLIED  ANATOMY.  [Chap,  xviu 

The  floor  of  tlie  pelvis  and  the  pelvic  fascia 

— The  outlet  of  the  bony  pelvis  is  occupied  in  the 
recent  state  with  the  following  sti-uctures  from  behind 
forwards :  the  pyriformis,  the  sacro-sciatic  ligaments, 
the  coccygeus,  the  levator  ani,  and  the  triangular 
ligament  of  the  urethra.  These  form  the  floor  of  the 
pelvis.  The  three  structures  last  named  serve  to 
separate  the  pelvic  cavity  from  the  perineum. 

The  walls  and  floor  of  the  pelvis  are  lined  by  a 
fascia,  the  pelvic  fascia,  of  which  a  brief  general 
description  may  be  given.  This  fascia  is  divided  into 
two  distinct  parts,  a  parietal  layer  and  a  visceral 
layer.  (1)  The  parietal  layer  begins  at  the  brim  of 
the  true  pelvis,  to  which  it  is  attached.  From  this 
attachment  it  passes  down  along  the  pelvic  wall,  forming 
a  lining  for  that  part,  covering  in  the  obturator  internus 
muscle,  and  becoming  adherent  below  to  the  rami  of 
the  pubes  and  ischium,  and  to  the  tuber  ischii.  Moro 
posteriorly  it  gives  a  thin  covering  to  the  pyriformis 
muscle.  (2)  The  visceral  layer  comes  off  from  the 
parietal  along  a  line  running  from  the  lower 
part  of  the  symphysis  pubis  to  the  ischial  spine. 
This  line  is  known  as  the  white  line,  and  corre- 
sponds to  the  origin  of  the  levator  ani  from  the  pelvic 
fascia. 

Starting  from  this  line  the  visceral  layer  passes 
down  into  the  pelvis  on  the  abdominal  surface  of  the 
levator  ani,  and  attaches  itself  to  all  the  pelvic  viscera 
with  which  it  comes  in  contact,  forming  fibrous  expan- 
sions or  "  ligaments,"  that  serve  to  hold  the  viscera  in 
place.  Were  there  no  pelvic  viscera,  this  layer  of 
the  fascia  would  be  continued  evenly  across  the  pelvic 
floor  from  one  side  to  the  other,  just  as  the  subperi- 
toneal  fascia  is  continued  over  the  under  surface  of 
the  diaphragm.  Having  given  "  reflections "  to  the 
pelvic  organs  the  visceral  layer  passes  on,  and,  covering 
the  opposite  levator  muscle,  ends  at  the  opposite  white 


Chap.  XVTII.]  THE  PELVIS.  381 

line.      This  visceral  layer  is   usually  known  as  the 
recto-vesical  fascia. 

As  regards  the  parietal  division,  it  will  be  seen 
that  that  part  of  it  above  the  origin  of  the 
visceral  layer  (i.e.,  above  the  white  line)  is  in  the 
pelvic  cavity,  while  that  part  below  the  line  is  in  the 
perineum.  To  this  lower  segment  the  name  obturator 
fascia  is  commonly  given.  Now,  the  peritoneum  lines 
some  part  of  the  pelvic  floor,  and  covers  a  great  part 
of  the  pelvic  viscera.  Between  this  peritoneum  and 
the  visceral  layer  of  the  pelvic  fascia  is  a  good  deal  of 
loose  connective  tissue.  Inflammation  may  be  set  up 
in  this  tissue,  may  spread  readily  in  it,  and  may 
of  course  lead  to  suppuration.  Such  suppuration 
will  be  limited  to  the  pelvic  cavity,  and  will  be 
hindered  from  escaping  from  that  cavity  by  the  pelvic 
fascia.  Inflammations  of  any  extent  so  located  are 
included  under  the  term  pelvic  cellulitis.  Suppura- 
tion, therefore,  above  the  visceral  layer  of  the  pelvic 
fascia  will  be  limited  to  the  pelvic  cavity,  while  that 
below  the  fascia  will  be  limited  to  the  perineum,  to 
either  the  urethral  or  the  anal  segment  of  that  district. 
Thus  it  will  be  seen  that  the  pelvic  fascia  is  of  much 
surgical  importance.  Wounds  through  the  perineum 
that  involve  this  fascia  will  be  serious,  in  that  they 
will  open  up  the  loose  tissue  on  the  pelvic  aspect  of 
the  fascia  in  which  inflammation  so  readily  spreads, 
while  unless  the  fascia  be  wounded  the  pelvic  cavity 
cannot  be  said  to  have  been  opened. 

The  fascia  is  so  reflected  upon  the  viscera  that  certain 
parts  of  them  are  excluded  by  the  attachments  of  the 
membrane  from  the  pelvic  cavity.  The  parts  so  ex- 
cluded are  the  following  :  the  prostate,  the  neck  of  the 
bladder,  all  that  part  of  the  base  of  the  bladder  that 
is  between  the  seminal  vesicles,  the  seminal  vesicles 
themselves,  and  about  the  last  two  and  a  half  or 
three  inches  of  the  rectum.  On  the  side  of  the 


382          SUKK/CJL  APPLIED  ANATOMY.   [Chap.xvm. 

rectum  the  fascia  reaches  the  level  of  a  line  drawn 
from  the  top  of  the  seminal  vesicles  to  the  middle  of  the 
fifth  piece  of  the  sacrum.  In  the  middle  line  it 
reaches  a  point  some  little  way  below  the  recto- 
vesical  cul-de-sac  of  the  peritoneum.  These  excluded 
portions  of  the  various  viscera  may  be  wounded 
without  the  pelvic  cavity  being  opened  up,  and 
suppuration  spreading  from  them  would  tend  to 
spread  towards  the  perineum,  and  not  into  the  pelvis. 
Pelvic  cellulitis,  to  use  the  term  in  the  strict  sense, 
means  inflammation  of  the  connective  tissue  between 
the  pelvic  fascia  and  the  peritoneum.*  This  connec- 
tive tissue  is  chiefly  situated  between  the  anterior 
wall  of  the  bladder  and  the  pelvis,  about  the  base  and 
neck  of  the  bladder,  between  the  latter  viscus  and  the 
rectum  ;  and  in  the  female,  between  the  layers  of  the 
broad  ligament  and  about  the  lower  part  of  the 
uterus  and  commencement  of  the  vagina.  All  this 
connective  tissue  is  continuous,  and  inflammation  in 
one  part  of  it  may  spread  to  the  other  parts.  In 
women  the  mischief  is  often  found  between  the  folds 
of  the  broad  ligament,  or  in  the  hollow  between  the 
uterus  and  the  rectum.  As  may  be  supposed,  the 
abscess  formed  in  such  cases  tends  to  mount  up  in  the 
pelvis,  being  unable  to  escape  below,  and  usually 
points  in  the  inguinal  region.  It  may,  however,  open 
into  one  of  the  pelvic  viscera  or  into  the  peritoneum, 
but  both  these  terminations  are  rare.  Out  of  thirty- 
seven  cases  of  puerperal  pelvic  cellulitis  with  suppu- 
ration, twenty-four  burst  externally,  and  for  the  most 
part  in  the  inguinal  region  (McClintock). 

It  should  be  borne  in  mind  that  the  blood-vessels 
of  the  pelvis  are  placed  on  the  peritoneal  aspect  of  the 
fascia.  The  branches  of  the  internal  iliac  artery, 
therefore,  that  leave  the  pelvis,  escape  by  piercing  that 

*  Clinically  the  term  pelvic  cellulitis  includes  also  pelvic  peri- 
tonitis, and  often  inflammation  of  one  or  other  of  the  viscera. 


chap,  xviii.]  THE  PERINEUM.  383 

membrane.  The  obturator  artery  is  an  exception  to  tliia 
rule,  since  it  passes  over  the  upper  border  of  the 
parietal  pelvic  fascia  (Cunningham).  The  nerves  in 
the  pelvis  lie  behind  or  outside  the  fascia,  and,  there- 
fore, the  pelvic  vessels  and  the  pelvic  nerves  are, 
excepting  the  obturator,  separated  from  one  another 
by  this  layer  of  tissue. 

The  male  perineum.  —  The  perineum  is  a 
lozenge-shaped  space  bounded  by  the  symphysis,  the 
rami  of  the  pubes  and  ischia,  the  ischial  tuberosities, 
the  great  sacro-sciatic  ligaments,  the  edges  of  the  two 
great  gluteal  muscles,  and  the  coccyx.  A  transverse 
line  drawn  across  the  space  between  the  anterior  ex- 
tremities of  the  tubera  ischii,  and  just  in  front  of 
the  anus,  divides  the  perineum  into  two  parts.  The 
anterior  part  forms  nearly  an  equilateral  triangle, 
measuring  about  three  and  a  quarter  inches  on  all 
sides.  It  is  called  the  urethral  triangle.  The  posterior 
part  is  also  somewhat  triangular,  contains  the  rectum 
and  ischio-rectal  fossa,  and  is  called  the  anal  triangle. 
The  whole  space  measures  about  three  and  a  half  inches 
from  side  to  side,  and  about  four  inches  from  before 
backwards  in  the  middle  line.  The  average  antero- 
posterior  diameter  of  the  pelvic  outlet  in  the  male 
averages  three  and  a  quarter  inches.  This  measure- 
ment in  the  undissected  subject  is  increased  to  four 
inches  by  the  curving  of  the  surface.  The  average 
transverse  diameter  of  the  male  pelvic  outlet  is  three 
and  a  half  inches,  and  corresponds  to  the  measurement 
of  the  perineum  above  given. 

The  bony  framework  of  the  perineum  can  be  felt 
more  or  less  distinctly  all  rcmnd,  and  in  thin  subjects 
the  great  sacro-sciatic  ligaments  can  be  made  out 
beneath  the  great  gluteal  muscle.  The  anus  is  in  the 
middle  line  between  the  tubera  ischii,  its  centre  being 
about  one  and  a  half  inches  from  the  tip  of  the 
coccyx.  The  raphe,  a  central  mark  or  ridge  in  the 


3*4 


SUKGICAL  APPLIED  ANATOMY.    [Chap.  xvi:i 


skin,  can  be  followed  from  the  anus  along  the  middle 
line  of  the  perineum,  scrotum,  and  penis.     No  vessels 


Fig.  36.— The  Male  Perineum.     (After  Riidinger.) 


cross  this  line,  and,  thei-efore,  in  making  incisions 
into  the  perineum  this  line  is  always  chosen  when 
possible.  In  the  middle  line,  midway  between  the 
centre  of  the  anus  and  the  spot  where  the  scrotum  joins 


Chap.  XVTII.I  THE  PERINEUM.  385 

the  perineum,  is  the  central  point  of  the  perineum. 
The  two  transverse  perineal  muscles,  the  accelerator 
urinse,  and  the  sphincter  ani  meet  at  this  point,  which 
also  corresponds  to  the  centre  of  the  inferior  edge  of 
the  triangular  ligament.  The  bulb  is  just  in  front  of 
it,  as  is  also  the  artery  to  the  bulb,  and  in  lithotomy, 
therefore,  the  incision  should  never  commence  in 
front  of  this  spot. 

The  perineal  space  is  separated  from  the  pelvic 
cavity  by  the  levator  ani  muscles  and  recto-vesical 
fascia,  as  already  mentioned.  The  depth  of  the  perineum 
means  the  distance  between  the  skin  and  the  pelvic 
floor.  This  depth  depends,  to  a  great  extent,  upon  the 
amount  of  fat  under  the  integument.  It  varies 
considerably  in  different  parts,  measuring  from  two  to 
three  inches  in  the  hinder  and  outer  parts  of  the 
perineum,  and  less  than  one  inch  in  the  anterior  parts 
of  the  space. 

The  iscliio-rcctal  fossa  is  of  pyramidal  shape, 
its  apex  being  at  the  white  line,  and  its  base  being 
formed  by  the  skin  between  the  anus  and  the  ischial 
tuberosities.  It  measures  about  two  inches  from  be- 
fore back,  one  inch  from  side  to  side,  and  is  between 
two  and  three  inches  in  depth.  Its  boundaries  are:  on 
the  outer  side,  the  obturator  internus  muscle  covered 
by  the  parietal  layer  of  the  pelvic  fascia;  on  the  inner 
side,  the  levator  ani,  covered  by  the  anal  fascia ;  in 
front,  the  base  of  the  triangular  ligament  and  the 
transversus  perinei  muscle ;  and  behind,  the  gluteus 
maximus,  great  sacro-sciatic  ligament,  and  coccygeus. 
The  pudic  vessels  and  nerves  are  on  the  outer  wall, 
embedded  in  the  fascia  over  the  obturator  muscle,  and 
are  placed  about  one  and  a  half  inches  above  the  lower 
border  of  the  tubera  ischii. 

The  part  of  the  rectum  which  occupies  the  space 
betweeii  the  two  fossre  is  supported  by  the  levatores 
ani,  external  sphincter,  and  recto-vesical  fascia.  Its 

Z— 4 


386  SURGICAL  Arrur.n  ANATOMY.  [Chap. xvm 

lateral  wall  is  exposed  for  a  distance  of  nearly  three 
inches,  its  posterior  wall  for  about  an  inch  (Quain). 
The  fossa  is  occupied  by  a  mass  of  fat  which  affords 
to  the  rectum  the  support  of  an  elastic  cushion.  This 
fatty  tissue  is  badly  supplied  with  blood,  and  this  fact, 
in  addition  to  the  dependent  situation  of  the  part,  and 
its  exposure  when  the  patient  sits  upon  damp,  cold 
seats,  etc.,  leads  to  abscess  being  very  frequent  in  the 
space  (ischio-rectal  abscess).  These  abscesses  are  hem- 
med in  on  all  sides,  soon  fill  the  fossa,  and  then  tend 
to  discharge  themselves  in  the  two  directions  where 
the  resistance  is  least,  viz.,  through  the  skin  and 
through  the  wall  of  the  rectum.  When  this  double 
discharge  of  the  abscess  has  taken  place,  a  complete 
fistula  in  atw  is  established.  It  is  well  to  note  that  in 
all  fistulse  in  ano  the  opening  into  the  rectum  is  nearly 
always  within  half  an  inch  of  the  anus.  An  opening 
into  the  bowel  higher  up  is  resisted  by  the  attachment 
of  the  levator  ani,  by  the  anal  fascia  and  by  the  recto- 
vesical  fascia. 

Crossing  the  space  obliquely  from  its  hinder  part 
to  the  anus  are  the  external  haemorrhoidal  vessels 
and  nerves ;  crossing  the  anterior  and  outer  corner 
of  the  fossa  are  the  perineal  vessels  and  nerves, 
and  about  the  posterior  border  of  the  space  are  the 
fourth  sacral  nerve  and  some  branches  of  the  small 
sciatic  nerve.  It  will  be  readily  understood,  therefore, 
that  ischio-rectal  abscesses  are  associated  usually  with 
extreme  suffering  until  they  are  relieved.  The  most 
severe  pain  is  probably  due  to  the  stretching  of  the 
external  hsemorrhoidal  nerve  by  the  abscess  as  it 
progresses  towards  the  surface.  In  opening  an  abscesa 
in  the  fossa  the  main  structures  to  avoid  are  the 
rectum,  the  pudic  and  external  hsemorrhoidal  vessels. 
Anns. — (See  paragraph  on  the  Rectum.) 
The  urethra!  triangle.— The  skin  of  the  peri- 
neum between  the  anus  and  the  scrotum  is  thin,  and 


chnp.  xvin.]  THE  PERINEUM.  387 

shows  very  readily  any  extravasations  of  blood  that 
may  form  beneath  it.  The  superficial  fascia  is  divided 
into  two  layers,  of  which  the  more  superficial  is  quite 
unimportant,  and  contains  what  little  subcutaneous 
fat  exists  in  this  part. 

The  deeper  layer,  known  as  the  perineal  fascia  or 
fascia  of  Colles,  is  attached  on  either  side  to  the  rami 
of  the  pubes  and  ischium,  and  behind  to  the  base  of 
the  triangular  ligament.  In  front  it  becomes  continuous 
with  the  dartos  tissue.  This  fascia,  therefore,  by  its 
attachments  forms  with  the  triangular  ligament  a  well- 
isolated  aponeurotic  space,  containing  the  bulb  with 
all  that  part  of  the  spongy  urethra  between  the 
triangular  ligament  and  the  attachment  of  the  scrotum, 
the  penile  muscles,  the  transverse  perineal  muscles, 
vessels,  and  nerves,  and  the  pevineal  vessels  and  nerves. 
When  extravasation  of  urine  follows  upon  a  rupture 
of  the  part  of  the  urethra  above  named,  the  course  of 
the  escaping  fluid  is  directed  by  the  fascia  of  Colles. 
It  fills  the  aponeurotic  space.  It  is  unable  to  gain  to 
ischio-rectal  fossa  on  account  of  the  attachment  of  the 
fascia  to  the  triangular  ligament.  The  lateral  attach- 
ments of  this  membrane  prevent  the  urine  from 
passing  into  the  thighs.  It  is,  therefore,  guided  into 
the  scrotum,  and  there  finds  itself  beneath  the 
dartos  tissue.  It  distends  the  scrotal  tissues,  and 
then  mounts  up  on  to  the  abdomen  through  the  gap 
left  between  the  symphysis  pubis  and  pubic  spine 
(page  291).  It  must  be  remembered  that  the  fascia 
of  Colles,  the  dartos  tissue,  and  the  deeper  layer  of 
the  superficial  fascia  of  the  abdomen,  are  continuous, 
and  merely  represent  different  parts  of  the  same 
structure.  Pus  or  blood  within  this  aponeurotic 
space  would  follow  the  same  course  if  the  effusion 
were  extensive  enough.  The  pain  occasioned  by 
such  effusion  can  be  understood  when  it  is  noted 
that  the  three  chief  sensory  nerves  of  this  region 


388          SURGICAL  APPLIED  ANATOMY,  [chap.  xvin. 

(the  three  long  scrotal  nerves)  are  included  within 
the  space. 

The  triangular  ligament  has  a  depth  of  about 
one  and  a  half  inches  in  the  middle  line,  and  is  formed 
of  two  layers,  of  which  the  posterior  is  derived  from 
the  pelvic  fascia.  The  membranous  urethra,  surrounded 
by  the  compressor  urethrae,  lies  between  the  two  layers, 
and  runs  about  one  inch  below  the  symphysis,  and 
about  three-quarters  of  an  inch  above  the  central  point 
of  the  perineum.  The  artery  to  the  bulb  passes  in- 
wards between  the  two  layers  about  half  an  inch  above 
the  base  of  the  ligament  and  one  inch  and  a-half  in 
front  of  the  anus.  The  dorsal  vein  and  the  terminal 
pai*t  of  the  pudic  artery  and  nerve  pierce  the  anterior 
layer  of  the  ligament  about  half  an  inch  below  the 
symphysis.  In  uncomplicated  rupture  of  the  mem- 
branous urethra,  the  urine  extravasated  would  be 
limited  to  the  space  beween  the  layers  of  the  ligament, 
until  subsequent  suppuration  had  made  a  way  for  it  to 
escape.  When  extravasation  occurs  behind  the  trian- 
gular ligament,  the  effusion  barely  escapes  the  pelvic 
cavity,  and  usually  by  following  the  rectum  gains  the 
anal  part  of  the  perineum. 

Just  beyond  the  triangular  ligament  is  the  pro- 
state, surrounded  by  its  capsule,  and  the  prostatic 
venous  plexus.  In  dissecting  down  from  the  surface 
to  the  prostate,  we  meet,  as  Cunningham  has  well 
pointed  out,  alternate  strata  of  fascial  and  muscular 
tissue,  forming  seven  layers  in  all,  viz.  :  (1)  Superficial 
fascia ;  (2)  superficial  perineal  muscles  ;  (3)  triangular 
ligament  (ant.  layer)  ;  (4)  compressor  urethrse  muscle  ; 
(5)  triangular  ligament  (post,  layer)  ;  (6)  levator  ani 
muscle  ;  (7)  capsule  of  prostate. 

Lateral  lithotomy. — The  first  incision  is  from 
two  to  three  inches  in  length,  is  commenced  just  to 
the  left  of  the  middle  line  and  just  behind  the  central 
point  of  the  perineum,  i.e.,  about  one  and  a  quarter 


chap,  xvin.)  THE  PERINEUM.  389 

inches  in  front  of  the  anus.  The  incision  is  carried 
downwards  and  outwards  into  the  left  ischio-rectal 
fossa,  and  ends  at  a  point  between  the  tuber  ischii  and 
posterior  part  of  the  anus,  and  one-third  nearer  to  the 
tuberosity  than  to  the  gut.  In  the  early  part  of  this 
incision  the  staff  may  just  be  touched,  as  it  lies  in  the 
membranous  urethra,  the  incision  becoming  more  and 
more  shallow  as  the  knife  is  withdrawn.  The  parts  cut 
in  the  first  incision  are  :  (1)  Skin  and  superficial  fascia; 
(2)  transverse  perineal  muscle, artery  and  nerve;  (3)  the 
lower  edge  of  the  anterior  layer  of  the  triangular 
ligament ;  (4)  the  external  hoemorrhoidal  vessels  and 
nerve. 

In  the  second  incision  the  knife,  guided  by  the  fore- 
finger of  the  left  hand,  is  passed  upwards  behind  the 
triangular  ligament,  is  engaged  in  the  groove  on  the 
staff  as  it  lies  in  the  membranous  urethra,  and  then, 
having  its  edge  turned  towards  the  left  tuber  ischii,  is 
steadily  earned  along  the  groove  into  the  bladder.  In 
this  incision  the  parts  divided  are:  (1)  Membranous  and 
prostatic  portions  of  urethra  ;  (2)  posterior  layer  of  tri- 
angular ligament;  (3)  compressor  urethrse;  (4)  anterior 
fibres  of  levator  ani  and  left  lateral  lobe  of  prostate. 
The  finger  is  then  introduced  along  the  staff  into  the 
bladder,  the  staff  is  removed,  and,  the  forceps  being 
inserted,  the  stone  is  extracted,  traction  being  made  in 
the  proper  axis  of  the  pelvis. 

Parts  that  may  be  wounded. — (a)  In  the  first  in- 
cision :  (1)  the  bulb,  or  the  artery  to  the  bulb.  These 
parts  can  be  avoided  by  commencing  the  incision  well 
behind  the  "  central  point,"  and  by  causing  the 
holder  of  the  staff  to  draw  it,  the  scrotum,  and  the 
penis  well  up.  The  staff  should  be  held  as  close 
up  under  the  pubes  as  possible.  The  bulb  is  very  small 
in  children,  large  in  adults,  and  largest  in  old  men. 
(2)  The  rectum  may  be  cut  if  much  distended,  or  if 
the  incision  be  made  too  vertical  or  carried  too  for 


390  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 

back.  In  all  cases  the  gut  should  be  well  emptied  \iy 
enema  before  the  operation.  (3)  The  pudic  vessels 
can  hardly  be  wounded  unless  the  incision  is  very 
carelessly  made,  and  the  knife  carried  almost  against 
the  bone  as  it  is  being  withdrawn.  (6)  In  the  second 
incision  the  knife  may  be  passed  beyond  the  prostate, 
and  may  so  incise  the  visceral  layer  of  the  pelvic 
fascia  as  to  open  up  the  pelvic  cavity.  It  will  be 
understood  that  the  lateral  lobe  of  the  prostate  may 
be  cut  freely  without  this  cavity  being  endangered. 
The  gland  is  enveloped  by  the  pelvic  fascia,  but  the 
incision  made  into  the  prostate  is  well  below  the  su- 
perior reflection  of  the  membrane.  The  incision  in  the 
neck  of  the  bladder,  therefore,  must  be  strictly  limited 
to  the  prostate.  The  prostatic  plexus  of  veins  cannot 
avoid  being  wounded.  The  left  ejaculatory  duct 
would  be  cut  if  the  prostatic  incision  be  carried  too 
far  backwards. 

In  children  the  pelvis  is  relatively  narrower  than 
in  the  adult,  the  bladder  is  more  an  abdominal  than 
a  pelvic  organ,  and  the  neck  of  the  bladder,  therefore, 
is  high  up.  The  viscus,  moreover,  is  very  movable, 
and  has  less  substantial  attachments  than  has  the 
adult's  bladder.  It  thus  happens  that  in  forcing  the 
linger  into  the  bladder  after  the  second  incision,  the 
viscus  has  actually  been  torn  away  from  the  urethra. 
In  children  the  prostate  is  rudimentary,  and  thus  more 
of  the  actual  neck  of  the  bladder  itself  has  to  be  cut. 
From  the  small  size  of  this  gland,  also,  it  happens  that 
in  some  cases  the  knife  has  passed  too  far  beyond  the 
prostatic  area,  and  has  opened  up  the  pelvic  fascia.  In 
children  also  the  peritoneum  descends  lower  on  the 
posterior  surface  of  the  bladder,  and  may  be  wounded 
by  a  careless  operator. 

Median  lithotomy.  —  In  this  operation  the 
knife  is  entered  in  the  middle  line,  just  in  front  of  the 
anus.  The  staff  has  a  central  groove,  and  the  point  of 


chap,  xviii.j  LITHOTOMY.  391 

the  knife  should  hit  the  instrument  as  near  as  possible 
to  the  apex  of  the  prostate.  As  the  knife  is  withdrawn, 
the  whole  of  the  membranous  urethra  is  incised,  and 
a  wound  made  in  the  median  raphe  of  about  one  inch 
and  a  quarter  in  length.  The  incision  is  made  by 
cutting  upwards.  A  probe  is  then  introduced  into  the 
bladder,  and,  the  staff  being  removed,  the  finger  is 
passed  into  that  viscus  by  steady  dilatation  of  the 
parts,  with  some  laceration  of  the  prostate.  The  object 
in  this  operation  is  to  enter  the  bladder  with  the  least 
amount  of  cutting,  and  by  dilatation  rather  than 
incision. 

Parts  divided. — (1)  Skin  and  superficial  fascia ; 
(2)  sphincter  ani ;  (3)  central  point  of  perineum  ;  (4) 
lower  border  of  triangular  ligament ;  (5)  whole 
length  of  membranous  uretlira  ;  (6)  compressor 
urethra. 

Advantages. — (1)  The  bleeding  is  much  less  than 
in  the  lateral  operation,  the  slight  vascularity  of  the 
raphe  being  well  known.  (2)  The  pelvic  fascia  is  much 
less  likely  to  be  wounded  if  the  bladder  be  entered  by 
dilatation  rather  than  by  incision,  as  in  the  lateral 
procedure. 

Disadvantages. — (1)  The  bulb  is  in  great  risk  of 
being  wounded.  It  must,  however,  be  noted  that 
wounds  of  the  bulb  in  the  middle  line  do  not  bleed 
readily,  as  a  rule.  (2)  The  amount  of  space  obtained 
for  the  removal  of  the  stone  is  very  slight.  (3)  In 
children  the  operation  in  its  integrity  is  scarcely  pos- 
sible, since  the  prostate  is  quite  rudimentary,  and  the 
.slight  attachments  of  the  parts  are  such,  that,  in  using 
forcible  dilatation,  the  bladder  may  readily  be  torn 
from  the  urethra.  If  the  incision  be  made  upwards, 
and  one  finger  be  retained  in  the  rectum,  the  risk  of 
wounding  the  gut  is  not  great. 

In  lithotomy,  and  in  other  operations  for  reaching 
the  neck  of  the  bladder  through  the  perineum,  it 


392  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 

should  be  remembered  that  the  bladder  lies  at  a  depth 
of  from  two  and  a  half  to  three  inches  from  the  sur- 
face when  the  body  is  in  lithotomy  position. 

Suprapubic  lithotomy. — This  operation  has 
been  revived  of  late  years,  and  is  especially  advised 
in  cases  of  large  stones,  and  in  male  children,  if 
lithotrity  is  contra-indicated,  to  avoid  the  large  wound 
in  the  prostatic  region.  In  order  to  bring  the  summit 
of  the  bladder  well  above  the  symphysis,  both  bladder 
and  rectum  are  dilated.  Into  the  former  viscus,  tepid 
water  or  boracic  lotion  is  injected.  It  is  found  that 
in  the  adult  eight  to  ten  ounces  is  sufficient  to  ensure 
the  desired  distension.  The  rectum  is  dilated  by 
means  of  a  soft  rubber  bag.  The  gut,  when  thus  dis- 
tended, pushes  forward  the  bladder,  and  gives  it  a 
firm  basis  upon  which  to  rest.  In  the  adult  from  ten 
to  fourteen  ounces  are  usually  introduced  into  the  bag. 
Without  the  rectal  bag  the  bladder,  distended  by  in 
jection,  would  sink  down  towards  the  pelvic  floor 
Distension  of  the  rectum  alone  will  elevate  the  bladder, 
but  it  will  usually  have  no  effect  upon  the  reflectioi/ 
of  peritoneum.  In  operating  upon  children  the  rectal 
bag  is  very  seldom  required.  In  the  case  of  a  male 
child,  aged  five,  the  injection  of  three  ounces  of 
water  into  the  bladder  caused  the  reflection  of  perito 
neum  to  mount  more  that  one  inch  above  the  sym- 
physis.  An  incision,  some  three  inches  in  length,  is 
made  immediately  above  the  symphysis  in  the  median 
line.  The  bladder  is  exposed  below  the  peritoneum, 
is  drawn  forwards  by  a  hook,  and  opened. 

The  bladder. — When  empty  the  bladder  is 
flattened  and  of  triangular  outline,  and  lies  against 
the  anterior  wall  of  the  pelvis.  The  empty  bladder 
may  be  found  in  one  of  two  conditions  (as  demon- 
strated by  Dr.  Hart  in  the  adult  female  bladder).  It 
may  be  small,  oval,  and  firm,  with  its  upper  wall 
convex  towards  the  abdomen.  In  vertical  antero- 


chap,  xviii.]  THE  BLADDER.  393 

posterior  section  the  urethra  foi  ms  with  the  cavity  of 
the  bladder  a  curved  slit  (the  systolic  empty  bladder). 
It  may  be  larger,  and  soft,  with  its  upper  surface  con- 
cave towards  the  abdomen,  and  fitting  into  the 
concavity  of  the  lower  wall  or  surface.  In  the  section 
named,  the  urethra  forms,  with  the  bladder  cavity,  a 
Y-shaped  figure,  the  two  diverging  limbs  of  the  Y 
corresponding  to  the  concavity  named  (the  diastolic 
empty  bladder).  When  moderately  distended  it 
is  of  rounded  outline ;  when  completely  distended 
it  assumes  an  oval  outline,  and  rises  out  of  the  pelvis. 
As  distension  of  the  bladder  increases,  the  summit  of 
the  viscus  is  brought  more  and  more  in  contact  with 
the  anterior  abdominal  wall,  the  organ  becoming  also 
more  convex  on  its  posterior  than  on  its  anterior  sur- 
face. This  tendency  for  the  summit  of  the  distended 
bladder  to  press  itself  against  the  anterior  parietes  is 
of  good  service  in  tapping  the  organ  above  the  pubes, 
and  in  suprapubic  lithotomy.  When  greatly  distended 
it  may  reach  the  umbilicus,  and  may  even  touch  the 
diaphragm.  The  usual  capacity  of  the  organ  is  about 
one  pint,  but  when  fully  occupied  it  may  hold  some 
quarts.  When  both  bladder  and  rectum  are  quite 
empty  the  apex  of  the  bladder  and  the  pre-vesical 
reflection  of  the  peritoneum  are  a  little  below  the 
upper  margin  of  the  syrnphysis  pubis.  As  the 
distended  bladder  ascends  above  the  pubes  it  dissects 
the  serous  membrane  from  the  parietes,  and  the  layer 
so  lifted  off  forms  a  cul-de-sac  or  fold  of  peritoneum 
between  the  upper  part  of  the  anterior  surface  of  the 
bladder  and  the  parietes.  When  the  apex  of  the 
bladder  is  two  inches  above  the  pubes  the  peritoneal 
reflection  is  probably  not  more  than  three-fourths  of 
an  inch  above  the  same  point  of  bone.  When  the 
apex  of  the  bladder  is  midway  between  the  umbilicus 
and  the  pubes  there  may  be  two  inches  (vertical)  of 
the  anterior  abdominal  wall  in  the  middle  line  and 


394  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 


Tig.  37. — A  Vertical  Antero-posterior  Section  of  the  Male  Pelvis 
(Braune). 

immediately  above  the  symphysis,  devoid  of  peritoneal 
lining.  Tims  it  happens  that  the  distended  viscus 
may  be  readily  tapped  above  the  pubes  without  tho 


chap,  xvin.]  THE  BLADDER.  395 

peritoneum  being  wounded.  As  the  bladder  becomes 
distended,  not  only  does  it  rise  into  the  abdomen,  but 
it  extends  also  towards  the  perineum,  diminishing  the 
length  of  the  prostatic  and  membranous  urethra.  In 
suprapubic  lithotomy  that  tendency  to  extend  down- 
wards is  prevented  by  the  rectal  bag  (page  392). 

Between  the  anterior  surface  of  the  bladder  and  the 
symphysis,  and  shut  in  by  the  peritoneum  above,  is  a 
loose  layer  of  connective  tissue.  The  looseness  of 
this  connective  tissue  permits  the  bladder  to  readily 
alter  its  dimensions  without  disturbing  the  connections 
of  the  organ.  In  injuries  to  the  pelvis  and  to  the 
front  of  the  bladder  a  diffuse  inflammation  may  be 
set  up  in  this  tissue  and  assume  serious  proportions. 
I  have  reported  a  case  where  an  extensive  suppuration 
in  this  area  followed  upon  aspiration  of  the  bladder 
above  the  pubes,  and  led  to  death.  Like  suppuration 
has  followed  suprapubic  lithotomy.  In  rupture  of 
the  anterior  wall  of  the  viscus  the  urine  escapes  into 
this  district  of  cellular  tissue ;  a  limited  suppuration 
may  follow  and  recovery  ensue. 

The  bladder,  although  fairly  fixed,  has  been  found 
in  inguinal,  femoral,  and  vaginal  hernias.  In  the  erect 
position  its  neck  (in  the  male)  lies  on  a  horizontal 
line  drawn  from  before  backwards  through  a  point  a 
little  below  the  middle  of  the  symphysis,  and  is  placed 
about  one  and  a  quarter  inches  (3  cm.)  behind  that 
articulation  (Tillaux). 

Relations  to  the  peritoneum. — The  anterior  surface 
is  entirely  devoid  of  peritoneum,  while  the  superior 
surface  is  entirely  covered  by  that  membrane.  At  the 
sides  there  is  no  peritoneum  in  front  of,  or  below,  the 
obliterated  hypogastric  arteries.  On  the  posterior 
aspect  of  the  bladder  the  serous  membrane  extends 
down  as  far  as  a  transverse  line,  uniting  the  upper 
parts  of  the  two  seminal  vesicles,  so  that  the  upper 
ends  of  the  vesicles,  as  well  as  the  ureters,  where 


396  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 

they  enter  the  bladder,  are  covered  by  peritoneum. 
This  recto-vesical  pouch  of  peritoneum  in  the  adult 
extends  to  within  about  three  inches  of  the  anus,  and 
does  not  reach  below  a  line  one  inch  above  the  base 
of  the  prostate.  Harrison  Cripps  gives  the  distance 
of  the  pouch  from  the  anus  as  2^  inches  when  the 
bladder  and  rectum  are  both  empty,  and  as  3i  inches 
when  those  viscera  are  distended.  (See  Bladder  in 
the  child,  page  400.) 

Puncture  of  the  bladder  per  rectum.— 
The  base  of  the  bladder  is  adherent  to  the  rectum  by 
dense  areolar  tissue  over  a  triangular  area,  the  apex 
of  which  is  formed  by  the  prostate,  the  sides  by  the 
diverging  seminal  vesicles,  and  the  base  by  the  recto- 
vesical  fold  of  peritoneum.  This  triangle  is  equi- 
lateral, and  in  the  dissected  specimen  measures  about 
one  and  a  half  inches  on  all  sides.  It  corresponds  to 
the  trigone  on  the  inner  surface  of  the  viscus.  It  is 
through  this  triangle,  and  as  near  as  possible  to  the 
prostate,  that  the  bladder  is  tapped  when  the  opera- 
tion is  performed  per  rectum.  The  recto-vesical  fold 
of  peritoneum  is  raised,  and  is  carried  still  farther 
from  the  anus  when  the  organ  is  distended. 

Rupture  of  bladder. — The  bladder  may  be 
ruptured  by  violence  applied  to  the  anterior  abdo- 
minal wall  apart  from  pelvic  fracture  or  external 
evidence  of  injury.  Such  a  rupture  can,  however, 
hardly  happen  to  the  empty  bladder,  which  should  be 
full  or  distended  at  the  time.  It  is  very  rare  for  the 
rupture  to  be  on  the  anterior  surface  only.  As  a  rule, 
the  tear  involves  the  superior  or  abdominal  surface, 
and  implicates  the  peritoneum.  The  injury,  therefore, 
is  very  fatal  (five  recoveries  out  of  seventy-eight  cases). 
In  some  cases  of  vesical  rupture  the  surgeon  has 
opened  the  abdomen,  and  has  stitched  up  the  rent  in 
the  viscus  with  perfect  success.  The  bladder  may  be 
torn  by  fragments  of  bone  in  fractures  of  the  pelvis, 


Chap,  xviii.]  THE  BLADDER.  397 

or  by  violence  applied  through  the  rectum  or  vagina. 
A  case,  for  example,  is  reported  (Holmes'  "  System  of 
Surgery  ")  of  a  man  who  fell  upon  a  pointed  stake 
fixed  in  the  earth.  The  stake  passed  through  the 
anus,  pierced  the  rectum,  and  entered  the  bladder  near 
the  prostate.  The  patient  recovered,  the  wound 
having  been  made  in  the  triangular  area  on  the  fundus 
of  the  bladder  alluded  to  above,  and  therefore  outside 
the  peritoneum.  The  viscus  may  be  ruptured  by  an 
accumulation  of  urine,  as  seen  in  cases  of  congenital 
closure  of  the  urethra  in  some  infants.  In  the  museum 
of  the  Royal  College  of  Surgeons  is  a  preparation  of 
"  the  bladder  of  a  woman  which  burst  near  the  entrance 
of  the  ureter  in  consequence  of  neglected  retention  of 
urine."  In  neglected  cases  of  stricture  in  the  male 
the  urethra  gives  way  rather  than  the  bladder,  and 
an  extravasation  of  urine  into  the  perineum  follows. 
A  small  puncture  of  the  bladder,  as,  for  example, 
that  made  by  a  fine  trochar,  is  at  once  closed  by  the 
muscular  contraction  of  its  wall. 

The  mucous  membrane  of  the  bladder  is  very 
lax,  to  allow  of  its  accommodating  itself  to  the  vary- 
ing changes  in  the  size  of  the  viscus.  Over  the 
trigone,  however,  it  is  closely  adherent,  and  were  it 
not  so  the  loose  mucous  membrane  would  be  constantly 
so  prolapsed  into  the  urethral  orifice  during  micturi- 
tion as  to  block  up  the  neck  of  the  bladder.  The 
trigone  is  bounded  by  three  orifices,  for  the  urethra 
and  the  two  ureters,  and  forms  an  equilateral  triangle, 
measuring  about  one  and  a  half  inches  on  all  sides.  It 
is  here  that  the  effects  of  cystitis  are  most  evident,  and 
the  unyielding  character  of  the  mucous  membrane 
over  the  trigone  serves  in  part  to  explain  the  severe 
symptoms  that  follow  acute  inflammation  of  that 
structure.  Since  the  oritice  of  the  urethra  forms  the 
lowest  part  of  the  bladder  in  the  erect  posture,  it 
follows  that  calculi  gravitate  towards  the  trigono,  and 


398  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvin. 

are  very  apt  to  irritate  that  part  of  the  interior.  The 
same  remark  applies  to  foreign  bodies  in  the  viscus. 
The  mucous  membrane  about  the  trigone  and  neck  is 
very  sensitive,  whereas  the  interior  of  the  remainder 
of  the  bladder  appears  to  be  singularly  defective  in 
common  sensation.  This  can  be  well  noted  in  using 
sounds  and  catheters. 

In  the  muscular  coat  of  the  viscus  the  fibres 
are  collected  into  bundles  which  interlace  in  all  direc- 
tions. When  the  bladder  becomes  hypertrophied 
these  bundles  are  rendered  very  distinct,  and  produce 
the  appearance  known  as  "fasciculated  bladder." 
This  simply  means  that  the  muscle  of  the  bladder, 
having  been  unduly  exercised  to  overcome  some 
obstruction  to  the  escape  of  urine,  increases  in  size, 
as  do  other  much  exercised  muscles,  and  that  increase 
serves  to  demonstrate  the  arrangement  of  the  indi- 
vidual bundles.  In  a  fasciculated  bladder  the  muscular 
bundles  present  much  the  appearance  of  some  of  the 
columnse  carnese  in  the  heart.  It  will  be  understood 
that  the  bladder  wall  between  the  muscular  bundles 
is  comparatively  thin,  and  may  yield  when  the  viscus 
is  distended.  By  such  distension  the  mucous  mem- 
brane becomes  bulged  out  between  the  unyielding 
muscle  bundles,  so  that  sacculi  are  formed,  and  the 
appearance  known  as  "  sacculated  bladder "  is  pro- 
duced. In  these  sacculi  urine  may  lodge  and  decompose, 
phosphatic  deposits  may  collect,  and  calculi  may 
develop  (encysted  calculi).  In  some  cases  the  parietes 
yield,  especially  at  one  part,  and  one  large  saccule  is 
produced.  In  this  way  a  sacculus  may  be  formed 
which  in  time  may  become  almost  as  large  as  the 
bladder  itself,  and  give  rise  to  the  erroneous  descrip- 
tions of  "  double  bladder,"  etc. 

The  anterior  wall  of  the  bladder  is  thicker  and 
stronger  than  the  posterior,  and  in  cases  of  hypertrophy 
the  increase  appears  to  mainly  involve  the  anterior 


Chap,  xvm.)  THE  BLADDER.  399 

wall.  The  difference  between  the  two  parts  is  well 
shown  in  frozen  sections  (Symington). 

The  ureters  run  for  three-quarters  of  an  inch  in 
the  muscular  wall  of  the  viscus,  and  their  oblique 
course,  together  with  the  action  of  the  muscular  tissue 
about  them,  tends  to  prevent  regurgitation  of  urine, 
In  cases  of  retention  the  ureters  become  distended ; 
but  this  is  due  rather  to  accumulation  of  urine  within 
them  than  to  its  reflux  from  the  bladder. 

In  cases  of  great  distension  of  the  bladder  the 
neck  of  the  viscus  is  opened  up  by  the  pressure  from 
within,  and  the  patient  exhibits  the  feature  of  over- 
flow of  urine. 

The  female  bladder  is  less  capacious  than  that 
of  the  male.  Its  neck  is  situate  a  trifle  nearer  to  the 
symphysis  than  it  is  in  the  male,  and  lies  in  a  hori- 
zontal line  continued  back  from  the  border  of  the 
symphysis.  There  being  no  prostate,  the  neck  of  the 
bladder  is  very  distensible,  and  this  fact,  taken  in 
connection,  with  the  shortness  and  dilatability  of  the 
urethra,  allows  of  most  stones  being  extracted  by 
forceps  without  cutting.  By  simple  dilatation,  stones 
of  a  diameter  of  three-quarters  of  an  inch  have  been 
removed.  Through  the  dilated  urethra  the  orifices  of 
the  ureters  can  be  seen  and  examined.  The  intimate 
relation  of  the  bladder  to  the  vagina  allows  it  to  be 
examined  well  from  the  latter  passage,  and  the  com- 
parative thinness  of  the  dividing  wall  serves  to  explain 
the  frequency  of  vesico-vaginal  fistulse.  Strange 
foreign  bodies  have  been  introduced  into  the  female 
bladder,  such  as  hair-pins,  crochet  hooks,  sealing-wax, 
penholders,  and  the  like. 

The  orifice  of  the  ureter  is  3  cm.  from  the  cervix 
uteri,  and  4  cm.  from  the  vesical  opening  of  the 
urethra.  Its  close  relation  to  the  cervix  renders  it 
liable  to  injury  in  supravaginal  amputation  of  that 
part,  and  in  certain  operations  on  the  uterus. 


400  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 

The  bladder  in  the  child  is  egg-shaped,  and 
its  vertical  axis  is  relatively  much  greater  than  it  is 
in  the  adult.  The  larger  end  of  the  egg-shaped 
cavity  is  directed  downwards  and  backwards.  It 
can  hardly  be  said  that  there  is  any  base  or  fundus 
to  the  child's  bladder.  The  viscus  is  situated  mainly 
in  the  abdomen,  the  pelvis  being  small  and  very 
shallow.  At  birth  the  orifice  of  the  urethra  is  on  a 
level  with  the  upper  edge  of  the  symphysis.  Although 
the  bladder  projects  so  freely  into  the  abdomen,  its 
anterior  wall  is  still  entirely  uncovered  by  peritoneum. 
On  the  posterior  wall  the  serous  membrane  extends 
lower  down  than  in  the  adult,  reaching  the  level  of 
the  urethral  orifice  at  the  time  of  birth,  and  the  level 
of  the  prostate  in  young  male  children.  The  prostate 
is  exceedingly  small  in  children.  Thompson  states  that 
at  the  age  of  seven  years  it  only  weighs  thirty  grains, 
whereas  in  subjects  between  eighteen  and  twenty 
it  weighs  two  hundred  and  fifty  grains.  The  bladder 
wall  in  the  child  is  so  thin  that  in  sounding  for  stone 
it  is  said  that  a  "  click "  may  be  elicited  by  striking 
the  pelvis  through  the  parietes  of  the  viscus. 

The  prostate. — The  prostate  is  situated  about 
three-quarters  of  an  inch  below  the  symphysis  pubis, 
and  rests  upon  the  rectum  in  front  of  the  bend  between 
the  second  and  third  segments  of  that  viscus.  It  is, 
therefore,  placed  within  one  andahalf  to  two  inches  from 
the  anus,  and  can  be  readily  examined  from  the  bowel. 

The  secretion  from  the  gland  is  discharged  through 
a  number  of  long  and  very  narrow  ducts.  In  certain 
forms  of  prostatic  imtation,  little  white  opaque  threads, 
very  nnich  like  short  pieces  of  cotton,  are  found  in  the 
urine,  and  are  actual  casts  of  the  prostatic  ducts. 

The  prostate  is  enveloped  in  a  firm  capsule 
derived  from  the  pelvic  fascia,  and  it  is  to  this  fascia 
that  we  look  for  an  explanation  of  the  course  of 
prostatic  abscess. 


chap.xvin.j  THE  PROSTATE  401 

The  prostatic  abscess  usually  bursts  into  the 
urethra,  that  being  the  direction  in  which  least 
resistance  is  encountered.  If  it  does  not  enter  the 
urethra,  it  will  probably  open  into  the  rectum,  there 
being  only  one  layer  of  the  pelvic  fascia,  and  that 
layer  not  a  thick  one,  between  the  two  organs. 
Indeed,  the  posterior  part  of  the  prostatic  capsule, 
and  the  anterior  part  of  the  sheath  of  the  rectum, 
are  continuous.  Failing  these  two  points  of  exit, 
the  abscess  may  progress  towards  the  perineum. 
This  course,  however,  is  not  very  usual,  the  advance 
of  the  abscess  being  resisted  by  the  dense  posterior 
layer  of  the  triangular  ligament,  with  the  lower  edge 
of  which  the  prostatic  capsule  is  continuous.  If  the 
abscess  reaches  the  perineum,  it  will  do  so  by  running 
along  the  side  of  the  rectum.  The  abscess  cannot 
make  its  way  into  the  pelvic  cavity,  its  movement  in 
that  direction  being  resisted  by  the  pubo-prostatic 
ligaments  which  form  one  of  the  very  densest  portions 
of  the  pelvic  fascia.  This  encasement  of  the  gland 
in  an  unyielding  membrane  will  serve  to  in  part 
explain  the  severe  pain  felt  in  acute  prostatic  abscess. 

Hypertrophy  of  the  prostate. — The  average 
measurements  of  the  normal  prostate  are  an  inch 
and  a  half  across  at  its  widest  part,  and  an  inch  and 
a  quarter  from  before  backwards,  or  from  apex  to 
base.  After  the  age  of  fifty-three  the  organ  is  very 
apt  to  become  hypertrophied ;  arid,  according  to  Sir 
Henry  Thompson,  this  hypertrophy  may  be  considered 
to  exist  when  the  gland  measures  two  inches  from 
side  to  side,  or  when  it  weighs  one  ounce.  The  usual 
weight  of  the  prostate  is  six  drachms.  If  the 
enlargement  mainly  affect  the  lateral  lobes,  it  will 
be  understood  that  the  hypertrophy  may  attain 
considerable  dimensions  without  retention  of  urine 
being  produced.  On  the  other  hand,  a  comparatively 
trifling  enlargement  of  the  middle  lobe  may  almost 
A  A — 4 


402  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 

entirely  block  the  orifice  of  the  urethra.  If  the 
affection  be  general,  the  prostatic  urethra  is  lengthened, 
and  if  one  lateral  lobe  be  more  enlarged  than  the 
other,  the  canal  deviates  to  one  side.  When  the 
enlargement  particularly  affects  the  middle  lobe,  the 
prostatic  urethra,  which  is  normally  almost  straight, 
becomes  considerably  curved,  the  curve  being  some- 
times very  abrupt. 

It  is  important  to  note  that  enlargement  of  the 
middle  lobe  alone  can  hardly  be  made  out  by  rectal 
examination. 

The  severity  of  the  symptoms  in  a  case  of 
hypertrophy  of  the  prostate  bears  little  or  no  relation 
to  the  the  apparent  size  of  the  gland  as  felt  per 
rectum.  A  portion  of  the  enlarged  body  may  pro- 
ject into  the  bladder.  This  usually  takes  the  form 
of  a  projecting  middle  lobe  which,  when  viewed  from 
the  interior  of  the  bladder,  may  appear  as  a  distinct 
well-rounded  pedunculated  or  sessile  growth. 

In  the  operation  of  prostatectomy  this  projecting 
and  most  troublesome  mass  is  removed  through  a 
suprapubic  incision.  Between  the  prostate  and  its 
capsule  is  an  extensive  plexus  of  veins,  the  prostatic 
plexus,  into  which  enters  the  dorsal  vein  of  the  penis. 
Phleboliths  are  said  to  be  more  frequently  met  with 
in  these  veins  than  in  any  other  in  the  body.  This 
plexus  is  cut  in  lateral  lithotomy,  and  it  is  through 
its  vessels  that  septic  matter  is  probably  absorbed  in 
cases  of  pyaemia  following  that  operation. 

The  male  urethra  is  about  eight  and  a  half 
inches  in  length  (21  cm.),  an  inch  and  a  quarter  being 
devoted  to  the  prostatic  urethra,  three-quarters  of  an 
inch  to  the  membranous,  and  six  and  a  half  inches 
to  the  penile  or  spongy  portion.  Between  the  ages  of 
four  and  six  years  its  length  is  8  to  9  cm.,  and  between 
ten  and  thirteen  years  10  to  11  cm.  The  canal  may 
be  divided  into  a  fixed  and  movable  part.  The  fixed 


chap,  xviii.]  THE  URETHRA.  403 

part  extends  from  the  neck  of  the  bladder  to  the 
posterior  extremity  of  the  penile  urethra  at  the  point 
of  attachment  of  the  suspensory  ligament.  The  fixed 
part  describes  an  even  curve,  fairly  represented  by 
the  line  of  a  "  short  curve "  metal  catheter.  The 
two  ends  of  the  curve  lie  about  in  the  same  line, 
viz,  one  drawn  across  the  lower  end  of  the  sym- 
physis,  and  at  right  angles  to  the  vertical  axis  of 
that  articulation.  The  curve  is  formed  around  this 
line,  its  summit  corresponding  to  a  prolongation  of 
the  vertical  axis  of  the  symphysis,  and  to  about  the 
centre  of  the  membranous  urethra.  This  part  of 
the  tube  lies  about  one  inch  below  the  pubic  arch. 
The  movable  portion  of  the  urethra  forms,  when  the 
penis  is  dependent,  a  second  curve  in  the  opposite 
direction,  so  that  the  whole  canal  follows  somewhat 
the  outline  of  the  letter  S. 

The  prostatic  portion  of  the  urethra  will  be  nearly 
vertical.  This  part  of  the  canal  corresponds  to  the  pos- 
terior ventral  part  of  the  urogenital  sinus  of  the  cloaca, 
which  receives  the  Wolffian  and  Miillerian  ducts.  The 
prostatic  sinus  in  this  part  of  the  urethra  represents  the 
united  ends  of  the  rudimentary  Miillerian  ducts. 

That  part  of  the  urethral  canal  which  lies  beyond  the 
prostate  is  of  different  origin,  and  is  a  portion  of  the 
anterior  segment  of  the  cloaca,  which  has  been  formed 
into  a  canal  by  a  superficial  union  of  the  tegumentary 
folds  in  the  median  line. 

The  penile  or  spongy  portion  of  the  urethra  is  sur- 
rounded by  the  erectile  tissue  of  the  corpus  spongiosum 
urethrae,  which  is  thickest  on  the  under  side  of  the  canal. 
A  very  thin  layer  of  erectile  tissue  surrounds  the  mem- 
branous urethra  lying  beneath  the  fibres  of  the  com- 
pressor urethrae. 

In  introducing  a  catheter  it  must  be  noted  that 
while  the  instrument  parses  along  the  movable 
urethra,  the  canal  accommodates  itself  to  the  catheter, 


404  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 

but  while  traversing  the  fixed  segment  the  instrument 
must  accommodate  itself  to  the  unyielding  canal.  In 
introducing  a  catheter  in  the  recumbent  posture  the 
penis  is  held  vertically  upwards,  and  in  this  way  the 
curve  formed  by  the  movable  urethra  is  obliterated. 
The  instrument  is  best  kept  close  to  the  surface  of  the 
groin,  and  over  and  pai'allel  to  Poupart's  ligament. 
When  the  fixed  urethra  is  reached,  the  handle  of  the 
catheter  is  brought  to  the  middle  line,  and  then,  being 
kept  strictly  in  the  median  plane  of  the  body,  is 
depressed  between  the  legs,  so  that  the  front  of  the 
instrument  may  follow  the  natural  curve  of  the 
canal.  The  greatest  difficulty  in  the  introduction  is 
generally  experienced  at  the  point  where  the  movable 
and  fixed  parts  of  the  urethra  meet ;  or,  rather,  in 
practice,  at  a  spot  a  little  behind  this  point,  viz.  at 
the  anterior  layer  of  the  triangular  ligament.  At  this 
spot  the  tube  becomes  abruptly,  not  only  very  fixed, 
but  also  very  narrow,  and  a  part  of  it  is  reached 
where  muscular  tissue  is  very  abundant,  and  where 
resistance  from  muscular  spasm  is  therefore  likely  to 
be  most  marked. 

It  thus  happens  that  when  a  false  passage  has 
been  made  by  a  catheter  in  a  case  where  no  stricture 
exists  to  offer  a  definite  obstruction,  the  instrument 
is  usually  found  to  have  left  the  canal  just  in  front  of 
the  triangular  ligament. 

Some  other  points  in  connection  with  catheterism 
will  be  noted  subsequently. 

The  urethra!  casial  must  not  be  regarded  as 
forming  an  open  tube  like  a  gas-pipe.  Except  when 
urine  or  an  instrument  is  passing  along  it,  the  tube 
appears  on  section  as  a  transverse  slit,  the  superior 
and  inferior  walls  being  in  contact.  This  fact  should 
be  remembered  in  amputation  of  the  penis  by  the 
ecraseur.  In  the  fossa  navicularis  the  tube  appears  as 
a  vertical  slit. 


chap,  xviii.]  THE  URETHRA.  405 

The  prostalic  part  of  the  canal  is  the  widest  and 
most  dilatable  portion  of  the  whole  urethra.  It  is 
widest  at  its  centre,  having  here  a  diameter  of  nearly 
half  an  inch  ;  at  the  bladder  end  its  diameter  is  about 
one-third  of  an  inch,  while  at  the  anterior  extremity  of 
this  part  of  the  urethra  the  measurement  is  a  little  less 
than  one-third  of  an  inch.  When  small  catheters  are 
being  introduced  their  points  may  lodge  in  the  orifice 
of  the  utricle,  unless  the  tip  of  the  instrument  be 
kept  well  along  the  roof  of  the  canal.  The  ejaculatory 
ducts  open  into  the  prostatic  urethra,  and  thus  it 
happens  that  inflammation  of  this  part  of  the  canal 
may  spread  back  along  those  ducts  to  the  seminal 
vesicles,  and  from  thence  along  the  vas  defevens  to 
the  epididymis.  It  is  by  spreading  along  these  parts 
that  inflammation  of  the  testicle  is  set  up  in 
gonorrhoea,  involving  the  prostatic  urethra,  and  it  will 
be  understood  that  a  like  inflammation  may  follow 
lateral  lithotomy,  impacted  stone  in  the  prostatic 
urethra,  prostatic  abscess,  and  the  like.  Stricture 
never  occurs  in  this  part. 

The  membranous  urethra  is,  with  the  exception 
of  the  meatus,  the  narrowest  part  of  the  entire  tube. 
Its  diameter  is  about  one-third  of  an  inch.  It  is 
fixed  between  the  two  layers  of  the  triangular  liga- 
ment, and  is  the  most  muscular  part  of  the  canal.  It 
is  at  this  spot,  therefore,  that  what  is  known  as 
"  spasmodic  stricture  "  usually  occurs.  In  any  case, 
the  contraction  of  the  compressor  urethras  often  offers 
an  appi'eciable  amount  of  resistance  to  the  passage  of 
a  catheter  or  sound. 

The  penile  urethra  is  dilated  at  either  end ;  viz. 
at  the  parts  occupying  the  bulb  and  the  glans  penis 
respectively.  The  diameter  of  the  bulbous  urethra 
is  midway  between  that  of  the  prostatic  and  mem- 
branous segments  of  the  canal,  while  that  of  the 
greater  part  of  the  penile  urethra  is  midway  between 


406  SURGICAL  APPLIED  ANATOMY.  [Chap.  XVIIT. 

that  of  the  bulbous  and  membranous  portions.  It  is 
in  the  bulbous  urethra  that  organic  stricture  is  the 
most  commonly  met  with.  The  meatus  measures 
from  one-fifth  to  one-fourth  of  an  inch,  and  therefoi-e 
if  a  catheter  will  pass  the  meatus  it  will  pass  along 
any  part  of  the  canal  if  normal.  Its  aperture  is  very 
resisting,  and  has  often  to  be  incised  to  allow  the 
larger  instruments  to  pass. 

The  narrowest  parts  of  the  urethra,  therefore,  are 
at  (1)  the  meatus,  and  (2)  in  the  membranous  segment, 
especially  at  its  anterior  end.  It  is  at  these  points  that 
calculi  passed  from  the  bladder  are  most  apt  to  lodge. 
The  widest  portions  of  the  canal,  on  the  other  hand,  are 
at  (1)  the  fossa  navicularis,  (2)  the  bulbous  part  of  the 
urethra,  and  (3)  the  centre  of  the  prostatic  portion. 

Keegan  has  shown  that  the  urethra  of  a  male 
child  two  or  three  years  of  age  will  take  a  No.  9 
catheter.  In  boys  between  eight  and  ten  years  a  No. 
1 1  lithotrite  may  be  passed. 

It  will  be  obvious,  therefore,  that  the  operation  of 
lithotrity  may  be  performed  upon  quite  young  male 
children,  and  that  fragments  of  crushed  calculus  of  no 
small  dimensions  may  be  removed  from  the  bladders 
of  such  patients  by  washing. 

The  mucous  membrane  presents,  in  addition 
to  many  mucous  glands,  several  lacunae,  the  orifices  of 
which  for  the  most  part  open  towards  the  meatus. 
These  lacunae  are  most  numerous  in  the  bulbous 
urethra,  and  occxipy  the  floor  leather  than  the  roof  of 
the  canal.  In  passing  small  catheters,  therefore,  the 
jK)int  of  the  instrument  should  be  kept  along  the 
upper  surface  of  the  tube,  so  that  it  may  not  become 
engaged  in  any  of  these  spaces.  The  largest  Jacuna, 
the  lacuna  magna,  is  situate  in  the  roof  of  the  fossa 
navicularis,  and  may  readily  engage  the  point  of  a 
small  instrument. 

Otis   has    endeavoured    to    show  that   a    definite 


Chap. xvin.]  THE  URETHRA.  407 

relation  exists  between  the  circumference  of  the  penis 
and  the  circumference  of  the  urethra,  a  relation 
represented  by  the  proportions  2 '25  :  1,  and  makes 
use  of  instruments  of  large  size,  which,  when  passed, 
seem  to  demonstrate  rather  the  dilatability  of  the  canal 
than  any  certain  anatomical  relationship. 

The  urethra  may  be  ruptured  by  the  patient 
falling  asti'ide  of  some  hard  substance.  In  such  an 
injury  it  is  crushed  between  the  hard  substance 
and  the  pubic  arch.  The  part  of  the  canal,  there- 
fore, that  is  most  often  damaged  is  the  membranous 
segment,  and  the  posterior  part  of  the  penile 
division.  The  more  the  body  is  bent  forwards  at  the 
time  the  perineum  is  struck,  the  greater  is  the  length 
of  penile  urethra  that  may  be  crushed  against  the 
pubes. 

The  female  urethra  is  about  one  and  a  half 
inches  in  length,  and  has  a  diameter  of  from  a  quarter 
to  one-third  of  an  inch.  It  is  capable,  however,  of 
great  distension.  In  the  erect  position  the  canal  is 
nearly  vertical,  and  in  the  recumbent  posture  almost 
horizontal. 

Penis. — The  skin  covering  the  bulk  of  the  organ 
is  thin  and  fine,  and  the  subcutaneous  tissue  is  scanty 
and  lax.  It  follows,  from  the  looseness  of  this  tissue, 
that  the  skin  is  very  distensible  and  movable.  The 
latter  fact  should  be  borne  in  mind  in  circumcision, 
for  in  performing  that  operation  the  skin  of  the  penis 
can  be  so  readily  drawn  forwards  over  and  beyond  the 
glans,  that  if  it  is  excised  as  far  back  as  possible  the 
greater  part  of  the  organ  may  be  left  bare.  This 
applies,  of  course,  mainly,  to  children.  The  laxity  of 
the  subcutaneous  tissue  permits  the  organ  to  become 
enormously  swollen  when  oedematous,  or  when  extra- 
vasated  urine  finds  its  way  into  the  part.  Over  the 
g'ans  penis  the  mucous  membrane  is  so  adherent 
that  there  is  practically  no  subcutaneous  tissue.  }t 


408  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 

happens,  therefore,  that  when  Hunterian  chancreg 
appear  on  this  part  they  can  never  be  associated  with 
other  than  the  most  trifling  induration,  there  being  no 
tissue  in  which  the  thickening  can  develop.  At  tho 
corona,  on  the  other  hand,  the  submucous  tissue  is 
lax  and  plentiful,  so  that  the  induration  can  readily 
form,  and  it  is  about  this  spot,  therefore,  that  the 
syphilitic  sore  attains  often  its  most  characteristic 
development.  The  vascularity  of  the  penis,  and  the 
rapid  engorgement  that  ensues  when  the  return  of  its 
venous  blood  is  impeded,  serve  to  explain  the  ready 
and  extensive  swelling  of  the  organ  that  follows  when 
any  constricting  baud  is  placed  about  it.  This  should 
be  borne  in  mind  in  tying  in  a  catheter  by  securing  it 
by  tapes  around  the  penis.  The  penis  is  often  the 
seat  of  arrests  of  development,  presenting  a  variety 
of  appearances.  Among  them  may  be  mentioned 
Jiypospadias,  where  the  inferior  wall  of  the  urethra 
and  corresponding  part  of  the  corpus  spongiosurn 
are  wanting,  and  epispadias,  where  the  superior  wall 
of  the  canal  and  corresponding  parts  of  the  corpora 
cavernosa  are  more  or  less  entirely  deficient. 

Scrotum. — The  skin  of  the  scrotum  is  thin  and 
transparent,  so  that  in  bruising  of  the  parts  the  dis- 
coloration due  to  the  extravasation  of  blood  beneath 
the  surface  is  readily  and  distinctly  seen.  It  is  also 
very  elastic,  and  allows  of  great  distension,  as  is  seen 
in  large  scrotal  hernise  and  testicular  tumours.  The 
integument  of  the  part  is  indeed  redundant,  and  the 
excision  of  a  portion  of  it  will  hardly  be  missed.  Even 
in  gangrene  of  the  scrotum,  when  both  testicles  have 
been  exposed,  the  parts  have  been  entirely  restored 
without  any  inconvenient  shrinking  or  contraction. 
The  rugae  on  the  surface  of  the  scrotum  favour  the 
accumulation  of  dirt,  and  the  irritation  set  up  by  such 
accumulation  may  be  the  exciting  cause  of  the  epi- 
theliomata  that  are  not  uncommon  in  this  part  When 


chap  xvni.]  THE  SCROTUM,  409 

the  surface  is  sweating,  the  rugae  tend  to  favour  a 
retention  of  the  moisture  between  their  folds ;  from 
this  and  other  circumstances  it  happens  that  the 
scrotum  is  liable  to  eczema  and  to  those  syphilitic 
skin  disorders  that  are  often  localised  by  irritation. 
The  rugae  are  a  sign  of  health,  since  they  depend 
upon  the  vigorous  contraction  of  the  muscle  fibres  in 
the  dartos  tissue.  In  the  enfeebled,  or  under  the 
relaxing  effects  of  heat,  the  scrotum  becomes  smooth 
and  pendulous.  In  lacerated  wounds,  especially  when 
portions  of  the  skin  are  torn  away,  the  dartos  is  of 
great  value  in  assisting  to  close  the  gap  by  its  contrac- 
tion, and  in  thus  covering  the  exposed  parts.  To  pro- 
mote such  contraction  the  wound  is  dressed  with  cold 
applications.  In  a  simple  incised  wound,  as  in  castra- 
tion, the  dartos  is  apt  to  turn  in  the  edges  of  the  skin 
and  cause  some  difficulty  in  applying  the  sutures. 
This  difficulty  may  be  avoided  by  relaxing  that  tissue 
for  a  while  by  the  application  of  a  warm  sponge  to  the 
wound. 

The  subcutaneous  tissue  is  lax  and  very  extensive, 
and  permits  of  considerable  extravasations  of  blood 
forming  beneath  the  surface.  It  is  unadvisable,  there- 
fore, to  apply  leeches  to  the  scrotum  itself,  since  they 
may  lead  to  an  undesirable  outpouring  of  blood  beneath 
the  skin,  and  to  the  appearance  of  a  considerable 
ecchymosis.  Leeches  in  testicular  affections  had 
better  be  applied  over  the  region  of  the  cord. 

The  scrotum,  from  its  dependent  position,  and 
from  the  looseness  and  extent  of  its  cellular  tissue,  is 
often  the  first  part  of  the  body  to  become  cedematous 
in  dropsy,  and  is  apt  to  show  that  redema  in  a  marked 
degree.  The  scrotum  also  is  the  part  most  fre- 
quently the  seat  of  elephantiasis,  which  is  due 
essentially  to  a  connective  tissue  change.  The  vitality 
of  the  scrotum  is  not  considerable,  and  it  there- 
fore not  unfrequently  sloughs  in  parts  when 


4To  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 

severely  inflamed.  For  this  reason  strapping  should 
be  applied  with  some  care  over  the  enlarged 
testis,  for  against  the  hard  mass  of  the  affected 
gland  the  integument  of  the  scrotum  can  be 
subjected  to  considerable  pressure  when  the  strap- 
ping is  tightly  applied.  In  such  a  case  I  have  seen 
the  whole  of  one  side  of  the  scrotum  slough  from  an 
indiscreet  use  of  this  familiar  method  of  treatment. 

The  laxity  of  the  subcutaneous  scrotal  tissues  is  an 
essential  feature  in  those  operations  for  the  radical 
cure  of  inguinal  hernia  where  the  fundus  of  the  sac  is 
invaginated,  through  an  incision  in  the  scrotum,  into 
the  orifice  of  the  inguinal  canal.  Lastly,  the  great 
mobility  of  the  scrotum  affords  an  admirable  source 
of  protection  to  the  testicle ;  for  when  the  part  is 
struck  or  squeezed  the  testis  can  slip  about  within 
the  scrotum,  as  a  smooth  ball  would  within  a  loose 
indiarubber  bag,  and  so  very  often  eludes  all  injury. 

The  testicle  may  be  retained  within  the  abdomi- 
nal cavity,  or  may  lodge  for  varying  periods  of  time,  or 
for  life,  in  the  inguinal  canal.  It  may,  on  the  other 
hand,  pass  beyond  the  scrotum  into  the  perineum,  or 
may  miss  the  inguinal  canal  altogether  and  escape 
through  the  femoral  canal  and  saphenous  opening  on 
to  the  thigh.  The  testis  proper  is  entirely  invested 
by  the  visceral  layer  of  the  tunica  vaginalis,  except 
over  a  small  part  of  its  posterior  border  where  the 
vessels  enter.  The  epididymis  is  entirely  covered 
with  the  serous  membrane  at  its  sides,  is  more  or  less 
so  covered  in  front,  but  is  free  or  uncovered  along  the 
greater  part  of  its  posterior  border.  It  is  about  the 
posterior  border  of  the  epididymis  that  the  visceral 
layer  of  the  tunica  vaginalis  joins  the  parietal  layer. 
It  is  mainly  by  this  uncovered  part  of  the  epi- 
didymis, and  by  the  vessels,  etc.,  that  enter  there,  that 
the  testicle  is  fixed,  for  were  the  whole  organ  to  be 
entirely  enveloped  by  the  serous  membrane,  it  would 


Chap,  xvin.]  THE  TESTICLE.  411 

lie  more  or  less  loosely  in  the  serous  cavity  as  lies  the 
small  intestine  in  the  abdomen.  The  more  intimate 
and  extensive  connection  of  tho  serous  tunic  with  the 
testis  or  gland  proper  serves  in  part  to  explain 
the  greater  frequency  with  which  hydrocele  appears 
in  inflammation  of  this  part  of  the  organ,  as  compared 
with  its  occurrence  when  the  epididymis  is  alone  in- 
flamed. It  is  owing  to  the  reflections  of  the  tunica 
vaginalis  that  in  cases  of  common  hydrocele  the  testicle 
remains  firmly  set  at  the  lower  and  posterior  pai-t  of 
the  swelling,  and  yet  so  extensively  is  the  organ  sur- 
roxmcled  by  that  membrane  that  the  position  of  the 
gland  in  the  larger  hydroceles  is  often  difficult  to  deter- 
mine. In  some  cases  the  testicle  occupies  the  front  of 
the  scrotum,  the  epididymis  being  placed  anterioi-ly, 
and  the  body  of  the  gland  being  located  behind  it. 
The  vas  deferens  descends  also  along  the  front  of  the 
cord.  In  these  cases  the  testicle  is  just  in  the  position 
it  would  occupy  if  it  had  been  turned  round  upon  its 
vertical  axis.  The  condition  is  known  as  inversion  oj 
the  testicle,  and  should  be  sought  for  in  cases  of  hydro- 
cele, as  in  several  instances  the  testis  has  been  pierced 
by  the  trochar  when  tapping  collections  in  which  the 
inversion  existed. 

The  proper  gland  tissue  is  invested  by  a  very  dense 
membrane,  the  tunica  albuginea.  The  epididymis,  on 
the  other  hand,  lacks  any  such  firm  fibrous  investment. 
The  unyielding  character  of  the  tunica  albuginea  serves 
in  great  part  to  explain  the  intense  pain  felt  in  acute 
affections  of  the  testis  proper,  a  degree  of  pain  which 
is  not  reached  when  the  less  tightly-girt  epididymis  is 
alone  involved.  It  will  be  understood  also  that  in  in- 
flammation of  the  epididymis  the  part  swells  rapidly 
and  extensively,  while  in  a  like  affection  of  the  body 
of  the  gland  the  swelling  is  comparatively  slow  to 
appear. 

The   tunica   albuginea   must  also  for   some  time 


4i2  SURGICAL  APPLIED  ANATOMY.  [Chap.  xvm. 

resist  the  growth  of  testicular  tumours.  When  the 
testicle  suppurates  and  matter  finds  an  escape  through 
the  skin,  it  is  the  unyielding  character  of  the  tunica 
albuginea  that  is  mainly  answerable  for  any  "fungus" 
that  may  form.  This  fungus  merely  means  the  escape 
of  swollen,  softened,  and  inflamed  structures  through  a 
hole  in  a  more  or  less  rigid  membrane,  and  were  that 
membrane  yielding  no  such  protrusion  would  form. 


Fig.  38.— Section  of  the  Left  Spermatic  Cord  of  an  Adult,  at  the  level 

of    the   External   Abdominal   Ring,  viewed  from   above.     (From  a 

specimen  prepared  by  Mr.  W.  G.  Spencer.) 
YD,    Vas   deferens;     DA,   deferential    artery;     DV,    deferential    veins;     SA, 

spermatic  artery  ;  CA,  creraasteric  artery ;  CM,  cremaster  muscle ;  PP,  iwuu- 

piniform  plexus. 

A  "fungus"  never  develops  in  connection  with  sup- 
puration of  the  epididymis  alone ;  at  the  most  an. 
abscess  of  that  part  will  lead  to  a  troublesome  sinus. 

It  should  be  borne  in  mind  that  the  lymphatics 
of  the  scrotum  go  to  the  inguinal  glands,  those  of  the 
testicle  to  the  lumbar. 

The  spermatic  cord. — The  structures  in  the 
cord  are  (1)  the  vas  deferens,  (2)  the  cremaster 
muscle  (3)  the  spermatic  and  (4)  cremasteric  arteries, 
and  (5)  the  artery  to  the  vas  deferens,  (6)  the  pam- 
piniform  plexus  of  veins,  (7)  the  genito-crural  nerve, 
(8)  sympathetic  nerve-fibres,  and  (9)  lymphatics.  The 
vas  deferens  lies  along  the  posterior  aspect  of  the  cord 
(Fig.  38),  and  can  be  detected  by  the  firm,  cord-like 
sensation  which  it  gives  when  pinched  between  the 


Chap,  xviii.]        THE  SPERMATIC  CORD.  413 

thumb  and  finger.  Mr.  Birketfc  (Holmes'  "  System  ") 
gives  three  cases  of  rupture  of  the  vas  deferens  during 
severe  and  svidden  exertion.  The  duct  appears  to 
have  in  each  case  given  way  within  the  abdomen  at 
some  point  between  the  internal  ring  and  the  spot 
where  it  approaches  the  ureter.  The  injury  is 
followed,  as  may  be  supposed,  by  atrophy  of  the 
corresponding  testicle.  The  size  of  cremaster  muscle 
depends  mainly  upon  the  weight  it  has  to  suspend. 
In  atrophy  of  the  testicle  it  almost  entirely  disappears, 
while  in  cases  of  large  slow-growing  tumours  of  the 
gland  it  attains  considerable  proportions.  If  in 
children  or  young  adults  the  skin  over  the  middle  of 
the  thigh  just  below  Poupart's  ligament  be  tickled 
the  testicle  of  the  same  side  will  usually  be  seen  to 
be  suddenly  drawn  upwards.  The  tickling  concerns 
the  crural  branch  of  the  genito- crural,  while  the 
motor  nerve  of  the  cremaster  is  the  genital  division 
of  the  same  trunk.  The  interval  of  time  that  elapses 
between  the  irritation  of  the  skin  and  the  movement 
of  the  testicle  has  been  appealed  to  as  affording 
evidence  of  the  state  of  nerve  health  and  of  the 
readiness  with  which  nerve  impulses  are  conducted, 
Of  the  arteries  the  spermatic  comes  from  the  aorta  and 
lies  in  front  of  the  vas,  the  cremasteric  arises  from 
the  deep  epigastric  and  lies  among  the  superficial 
layers  of  the  cord  in  its  outer  segment,  while  the 
deferential  artery  from  the  superior  or  inferior  vesical 
lies  by  the  side  of  tho  vas  (Fig.  38).  The  first-named 
vessel  is  the  size  of  the  posterior  auricular,  and  the 
two  latter  the  size  of  the  supraorbital.  The  three 
arteries  of  the  cord  are  divided  in  castration,  and  may 
all  require  ligature.  It  is  advisable  to  secure  the 
vessels  in  sections,  rather  than  adopt  the  clumsy  plan 
of  involving  the  whole  cord  in  one  common  ligature. 
The  veins  are  divided  roughly  into  two  sets.  The 
anterior  is  by  far  the  larger  set,  runs  with  the 


414  SURGICAL  APPLIED  ANATOMY.  [Chap. xvm. 

spermatic  artery  and  forms  the  pampiniform  plexus. 
The  posterior  set  is  small  and  surrounds  the  vas, 
running  with  the  deferential  artery.  The  veins  of 
the  spermatic  or  pampiniform  plexus  are  very 
frequently  varicose,  and  then  constitute  the  affection 
known  as  vai'icocele.  Many  anatomical  causes 
render  these  veins  liable  to  this  affection :  they 
occupy  a  dependent  position,  and  the  main  vein  is  of 
considerable  length,  and  follows  a  nearly  vertical 
course  ;  the  vessels  are  very  large  when  compared 
with  the  corresponding  artery,  and  so  the  vis  a  tergo 
must  be  reduced  to  a  minimum ;  they  occupy  a  loose 
tissue,  and  are  lacking  in  support  and  in  the.  aid 
afforded  to  other  veins  (as  in  the  limbs)  by  muscular 
contraction ;  they  are  very  tortuous,  form  many 
anastomoses,  and  have  few  and  imperfect  valves  ;  they 
are  exposed  to  pressure  in  their  passage  through  the 
inguinal  canal.  The  left  veins  are  more  frequently 
affected  than  the  right.  Mr.  Spencer  has  shown  that 
the  veins  in  the  left  cord  are  always  much  larger 
than  those  of  the  right.  It  may  also  be  pointed  out 
that  the  left  testicle  hangs  lower  than  ths  right ;  that 
the  left  spermatic  vein  enters  the  left  renal  at  a  right 
angle,  while  the  right  spermatic  vein  passes  obliquely 
into  the  vena,  cava ;  and  that  the  left  vein  passes 
beneath  the  sigmoid  flexure,  and  is  thus  exposed  to 
pressure  from  the  contents  of  that  bowel.  The  congenital 
origin  of  varicocele  is  now  very  generally  allowed. 

When  the  varicose  veins  are  exposed  by  operation  it 
is  impossible  to  isolate  or  even  recognise  the  arteries. 

The  female  generative  organs  require  but 
little  notice  in  the  present  volume.  The  labia  majora 
have  the  same  pathological  tendencies  as  has  the 
scrotum,  to  which,  indeed,  they  anatomically  corre- 
spond. They  are  liable  to  present  large  extravasa- 
tions of  blood,  are  greatly  swollen  when  cedematous, 
are  prone  to  slough  when  acutely  inflamed,  and  are 


Chap,  xviii.]  THE  RECTUM.  415 

the  usual  seats  of  elephantiasis  in  the  female.  A 
hernia  may  present  in  one  or  other  labium  (pudendal 
hernia),  the  neck  of  the  sac  being  between  the  vagina 
and  the  pubic  ramus. 

"  On  everting  one  of  the  labia  minora  and  pressing 
the  hymen  inwai'ds,  a  small  red  depression  may 
generally  be  seen  on  the  vulva,  somewhat  posteriorly. 
It  leads  to  the  orifice  of  Cowper's  duct"  (Doran). 
Cowper's  gland,  an  oval  body  about  half  an  inch  in 
length,  lies  against  the  posterior  part  of  the  vaginal 
orifice,  under  the  superficial  perineal  fascia,  and 
covered  by  the  fibres  of  the  sphincter  vaginae.  It 
wastes  after  thirty.  Abscess  of  the  gland  and  cystic 
dilatation  of  its  duct  are  not  uncommon. 

The  vagina  is  lodged  between  the  bladder  and 
rectum,  while  the  upper  fourth  of  its  posterior  surface 
is  covered  with  peritoneum,  and  is  therefore  in  relation 
to  the  abdominal  cavity.  Thus  it  happens  that  the 
bladder,  the  rectum,  or  the  small  intestines,  may 
protrude  into  the  vagina  by  a  yielding  of  some  parts 
of  its  walls  and  thus  produce  a  vaginal  cystocele, 
rectocele,  or  enterocele. 

The  anterior  wall  of  the  vagina  measures  a  little 
over  two  inches,  the  posterior  wall  about  three  inches. 
The  long  axis  of  the  canal  forms  an  angle  of  60°  with 
the  horizon,  and  is  therefore  almost  parallel  to  the 
pelvic  brim. 

The  abdominal  cavity  may  be  opened  through  a 
wound  of  the  vagina.  In  one  or  two  instances  of  such 
injuries  several  feet  of  intestine  have  protruded 
through  the  vulva.  In  one  reported  case  an  old 
woman,  the  subject  of  a  brutal  rape,  walked  nearly  a 
mile  with  several  coils  of  the  small  bowel  hanging 
from  her  genitals. 

From  the  comparative  thinness  of  the  walls  that 
separate  the  vagina  from  the  bladder  and  rectum,  it 
happens  that  vesico- vaginal  and  recto-vaginal  fistulas 


4i 6  SURGICAL  APPLIED  ANA TOMY.  [Chap.  xvm. 

are  of  frequent  occurrence.  The  vagina  is  very  vascular, 
and  wounds  of  its  walls  have  led  to  fatal  haemorrhage. 
It  is  very  dilatable,  as  can  be  shown  when  the  canal 
is  plugged  to  arrest  haemorrhage  from  the  uterus. 

The  uterus  weighs  about  one  ounce.  The  uterine 
cavity  and  the  cervical  canal  together  measure  about 
two  and  a  half  inches.  This  must  be  borne  in  mind 
when  passing  a  uterine  sound.  The  blood-vessels  run 
transversely  to  the  length  of  the  uterus,  so  that  a 
ligature  may  be  placed  completely  around  the  organ 
without  affecting  the  circulation  above  or  below. 

The  unimpregnated  uterus  is  very  rarely  wounded, 
owing  its  imimmity  to  the  denseness  of  its  walis,  to 
its  small  size,  to  its  great  mobility,  and  to  its  position 
within  the  bony  pelvis. 

The  ovary  is  so  placed  that  the  outer  part  of 
the  Fallopian  tube  turns  downwards  external  to  it. 
"  Both  ovaries  lie  in  a  sagittal  plane  against  the  side 
walls  of  the  pelvis,  with  their  long  axes  nearly 
vertical ;  so  that  their  surfaces  are  internal  and 
external,  borders  anterior  and  posterior,  and  ex- 
tremities upper  and  lower  "  (Symington).  The  main 
ovarian  vessels  lie  close  to  the  outer  part  of  the 
organ,  after  passing  along  a  short  fold  of  peritoneum, 
which  runs  from  the  brim  of  the  pelvis  to  the  ovary, 
and  is  termed  the  infunclibulo-pelvic  ligament.  This 
ligament  forms  the  outer  part  of  the  pedicle  in 
ovariotomy. 

The  rectum  in  the  adult  is  situated  entirely 
within  the  true  pelvis,  and  presents  three  marked 
curves,  one  in  the  lateral  and  two  in  the  antero- 
posterior  direction.  (See  page  347.)  In  the  infant, 
however,  a  good  deal  of  the  rectum  is  in  the 
abdominal  rather  than  the  pelvic  cavity,  the  gut  is 
nearly  straight,  and  occupies  a  more  or  less  vertical 
position.  For  these  reasons,  together  with  the  fact 
that  the  sacrum  is  straight,  the  prostate  small,  and 


Chap,  xviii.j  THE  RECTUM.  417 

the  connections  of  the  bowel  loose,  prolapsus  ani  is 
much  more  common  in  children  than  in  adults. 
Children  are,  besides,  especially  liable  to  such  exciting 
causes  of  prolapse  as  worms  and  rectal  polypi. 

The  rectum  is  about  eight  inches  in  length.  Its 
upper  pai't,  for  some  three  inches,  is  entirely  invested 
by  peritoneum.  The  serous  membrane  gradually 
leaves  its  posterior  surface,  then  its  sides,  and  lastly 
its  anterior  surface.  Anteriorly,  the  peritoneum,  in 
the  form  of  the  recto-vesical  pouch,  extends  in  the 
male  to  within  three  inches  of  the  anus,  while  on 
the  posterior  aspect  of  the  gut  there  is  no  peritoneum 
below  a  spot  five  inches  from  the  anus.  Thus,  in 
excision  of  the  rectum,  more  of  the  bowel  can  be 
removed  on  the  posterior  than  on  the  anterior  part  of 
the  tube.  It  will  be  seen,  also,  that  carcinomatous 
and  other  spreading  ulcers  are  more  apt  to  invade  the 
peritoneal  cavity  when  they  are  situated  in  the  anterior 
wall  of  the  intestine.  The  internal  sphincter 
surrounds  the  lower  part  of  the  rectum,  an  inch  above 
the  anus,  and  extends  over  about  half  an  inch  of  the 
intestine.  Mr.  Cripps  has  shown  that  the  posterior 
edge  of  the  levator  ani  forms  a  distinctly  felt  free 
border,  which  crosses  the  rectum,  neai-ly  at  a  right 
angle  at  a  point  from  one  and  a  half  to  two  inches 
from  the  anus. 

By  inserting  the  finger  into  the  rectum  the  pro- 
state and  seminal  vesicles  can  be  readily  felt  and 
examined,  and  that  triangular  surface  of  the  bladder 
explored  through  which  puncture  per  rectum  is  made 
(page  396). 

It  will  be  understood  that  the  prostate,  when 
enlarged,  may  encroach  upon  the  cavity  of  the  rectum 
and  greatly  narrow  its  lumen.  The  position  of  the 
seminal  vesicles  with  regard  to  the  bowel  is  such  that 
in  violent  attempts  at  defsecation  they  may  be  pressed 
upon  by  the  rectal  contents,  and  so  in  part  emptied. 
B  B— 4 


4i S          SURGICAL  APPLIED  ANATOMY,    [chap.  XVIIL 

producing  a  kind  of  spennatorrhrea,  Def?ecation  also 
often  causes  much  pain  in  inflammatory  affections  of 
the  prostate  and  adjacent  parts. 

The  anterior  surface  of  the  rectum  in  the  female 
is  in  relation,  so  far  as  the  finger  can  reach,  with  the 
vagina,  and  in  examining  the  lower  part  of  the 
rectum,  it  is  convenient  to  protrude  its  mucous  mem- 
brane through  the  anus  by  means  of  the  finger  intro- 
duced into  the  genital  passage. 

The  rectum  is  dilated,  and  is  very  distensible  just 
above  the  anus.  In  faecal  accumulations  it  may  be  dis- 
tended to  a  considerable  size,  and  strange  foreign 
bodies  of  large  dimensions  have  been  found  in  the 
ampulla.  Among  the  latter  may  be  mentioned  a 
bullock's  horn,  an  iron  match-box,  and  a  glass  tumbler. 
Experiment  has  shown  that  when  the  rectum  is  dis- 
tended in  the  male,  the  recto- vesical  fold  of  peritoneum 
is  raised,  and  the  bladder  is  elevated  and  pushed  for- 
wards. In  the  female  the  fundus  uteri  is  raised  and 
pushed  towards  the  symphysis.  The  rectum  is  arti- 
ficially distended  in  suprapubic  lithotomy,  in  order  to 
bring  the  bladder  into  better  position  (page  392). 

If  the  sphincter  be  very  gradually  dilated,  the 
entire  hand,  if  small,  may  be  introduced  into  the 
rectum  in  both  males  and  females.  The  circumference 
of  the  hand  should  not  exceed  eight  inches.  By  a 
semi-rotary  movement,  and  by  alternately  flexing  and 
extending  the  fingers,  the  hand  can  be  insinuated 
into  the  commencement  of  the  sigmoid  flexure. 
Owing  to  the  mobility  of  this  part  of  the  bowel  a 
large  extent  of  the  abdomen  may  be  explored  through 
the  bowel  wall.  The  structures  that  can  be  readily 
felt  are  the  kidney,  the  aorta,  the  iliac  vessels,  the 
uterus  and  ovaries,  the  bladder  and  its  surroundings, 
the  pelvic  brim,  the  sacro- sciatic  foramina,  the  ischial 
spine,  the  sacrum,  etc.  In  some  subjects  even  a 
small  hand  cannot  be  passed  beyond  the  reflection  of 


chap,  xvi ii.]  THE  RECTUM.  419 

the  peritoneum  over  the  second  part  of  the  gut.  In 
such  instances  the  peritoneum  offers  a  resistance  like  a 
tight  garter,  and  prevents  the  farther  advance  of  the 
hand  without  great  risk  of  laceration  of  the  parts " 
(Walsham). 

Owing  to  the  constrained  position  of  the  hand  and 
the  cramping  of  the  fingers,  this  method  of  examina- 
tion has  proved  to  be  of  but  limited  service. 

Mr.  Davy  has  invented  a  wooden  "  lever,"  by 
which  the  common  iliac  arteries  may  be  compressed 
against  the  pelvic  brim  through  the  rectum.  The 
lever  has  been  used  in  arresting  haemorrhage  during 
amputation  through  the  hip  joint. 

The  attachments  of  the  rectum  by  means  of  the 
pelvic  fascia  are  not  very  firm  ;  since,  in  some  severe 
and  rare  cases  of  prolapse,  all  the  walls  of  the  gut 
may  be  protruded  at  the  anus.  In  excision  of  the 
rectum,  also,  advantage  is  taken  of  this  mobility. 
In  that  operation  the  lower  two  inches  or  more 
of  the  bowel  may  be  removed,  and  the  remaining  part 
of  the  tube  drawn  down,  if  necessary,  so  that  its  mucous 
membrane  can  be  stitched  to  the  edges  of  the  wound. 

The  mucous  membrane  is  thick,  vascular,  and  but 
loosely  attached  to  the  muscular  coat  beneath.  This 
laxity,  which  is  more  marked  in  children,  favours  pro- 
lapse, an  affection  in  which  the  mucous  membrane  of 
the  lower  part  of  the  rectum  is  protruded  at  the  anus. 
The  mucous  membrane  presents  three  prominent  semi- 
lunar  folds,  about  half  an  inch  in  depth,  which  are 
placed  more  or  less  transversely  to  the  long  axis  of  the 
bowel.  The  first  projects  backwards  from  the  fore 
yart  of  the  rectum  opposite  the  prostate,  the  second 
projects  inwards  from  the  left  side  of  the  tube  opposite 
the  middle  of  the  sacrum,  the  third  is  near  the  com- 
mencement of  the  bowel  on  the  right  side.  These 
folds,  especially  when  the  gut  is  empty,  may  offer  con- 
siderable resistance  to  the  introduction  of  a  bougie  or 


420  SuRGfCAL  ArrLiED  ANATOMY.  [Chap.  xvm. 

long  enema  tube,  and  their  position  should  be  therefore 
borne  in  mind. 

The  vessels,  and  especially  the  veins,  at  the  lower 
part  of  the  rectum,  are  apt  to  become  varicose  and 
dilated,  and  form  piles.  The  tendency  to  piles  can 
in  part  be  explained  by  the  dependent  position  of  the 
rectum,  by  the  pressure  effects  of  hardened  faeces 
upon  the  returning  veins,  and  by  the  fact  that  part 
of  the  venous  blood  returns  through  the  systemic 
system  (internal  iliac  vein)  and  part  through  the 
portal  system  (inferior  mesenteric  vein).  This  con- 
nection with  the  portal  trunk  causes  the  rectum  to 
participate  in  the  many  forms  of  congestion  in- 
cident to  that  vein.  The  veins  of  the  rectum,  also, 
can  be  affected  by  violent  expiratory  efforts.  For 
the  last  four  inches,  moreover,  of  the  bowel,  the  ar- 
rangement of  the  vessels  is  peculiar,  and  is  such  as  to 
favour  varicosity.  The  arteries,  "having  penetrated 
the  muscular  coats  at  different  heights,  assume  a  longi- 
tudinal direction,  passing  in  parallel  lines  towards  the 
edge  of  the  bowel.  In  their  progress  downwards  they 
communicate  with  one  another  at  intervals,  and  they 
are  very  freely  connected  near  the  orifice,  where  all 
the  arteries  join  by  transverse  branches  of  consider- 
able size  "  (Quain).  The  veins  form  a  plexus  with  a 
precisely  similar  arrangement. 

A  LUIS. — The  skin  about  the  anus  is  thrown  into 
numerous  folds,  and  it  is  in  these  that  the  ulcer 
or  fissure  of  the  anus  forms.  The  extreme  painful- 
ness  of  these  ulcers  is  due  to  the  exposure  of  a  nerve- 
fibre  at  their  base,  and  to  the  constant  contraction  of 
the  sphincter  muscle  that  they  excite.  Relief  is  given 
by  incising  the  base  of  the  ulcer,  so  as  to  divide 
some  part  of  the  sphincter ;  or  by  violently  dilating 
the  anus,  so  as  to  tear  up  the  base  of  the  ulcer  and 
paralyse  for  a  while  the  action  of  the  disturbing 
muscle.  A  fine  white  line  around  the  anus,  at  the 


Chap,  xviii.j      PELVIS  AND  PERINEUM.  421 

junction  of  the  skin  and  mucous  membrane,  indi- 
cates the  interval  between  the  external  and  internal 
sphincters  (Hilton). 

The  anus  may  be  torn  during  defaecation,  when 
the  stools  are  hard.  A  case  is  reported  of  a  woman, 
who,  during  violent  efforts  at  defaecation,  felt  something 
give  way,  and  discovered  faeces  in  her  vagina.  The 
recto-vaginal  wall  had  ruptured  two  inches  from  the 
anus.  During  labour,  the  child's  head  has  passed  into 
the  rectum,  and  has  been  delivered  per  anum. 

As  congenital  defects,  the  anus  and  entire  rectum 
may  be  absent ;  or  the  anus  be  not  evident,  and  the 
rectum  be  more  or  less  complete ;  or  the  anus  and 
lowest  part  of  the  rectum  may  be  normal,  and  the 
upper  part  of  the  bowel  be  quite  wanting. 

Nerves  of  pelvis  and  perineum.  —  The 
pelvic  viscera  are  supplied  by  the  pelvic  plexus  of 
the  sympathetic.  This  plexus  is  joined  by  at  least 
three  spinal  nerves,  the  second,  third,  and  fourth 
sacral. 

It  is  well  known  that  in  certain  affections  of  the 
bladder,  rectum,  prostate,  etc.,  pain  is  felt  along  the 
perineum,  in  the  penis,  over  the  buttock,  and  down 
the  thigh.  These  parts  are  supplied  by  the  puclic 
and  small  sciatic  nerves,  and  the  reason  for  the  pain 
is  explained  by  noticing  that  the  very  spinal  nerves 
that  join  the  plexus  for  the  viscera  give  off  also  the 
pudic  and  small  sciatic  nerves,  the  former  from  the 
third  and  fourth  sacral,  the  latter  from  the  second 
and  third.  Thus,  the  pelvic  viscera,  and  the  skin  of 
the  buttock,  perineum,  and  external  genitals  are  all 
kept  iu  association  by  the  same  spinal  nerves. 
The  upper  part  of  the  rectum  is  provided  with  but 
little  sensation,  as  illustrated  by  the  passage  of  instru- 
ments, by  the  comparative  painlessness  of  malignant 
and  other  growths  high  up  in  the  bowel,  and  by  the 
little  inconvenience  felt  when  the  gut  is  distended 


422  SURGICAL  APPLIED  ANATOMY.  [Chap,  xviu 

with  hardened  faeces.  From  this  apathy  it  has  pro- 
bably happened  that,  in  the  self-administration  of 
enemata,  patients  have  thrust  the  tube  through  the 
rectum  into  the  peritoneal  cavity.  The  last  two 
inches  of  the  bowel,  on  the  other  hand,  are  extremely 
sensitive. 

The  pain  at  the  end  of  the  penis  felt  in  prostatic 
affections,  and  in  stone,  or  other  maladies  involving 
the  bladder  neck,  is  probably  explained  by  the  fact 
that  the  prostatic  nerve  plexus  (that  supplies  both 
the  gland  and  the  neck  of  the  bladder)  is  continued 
to  the  end  of  the  penis  as  the  cavernous  plexus.  It 
terminates  at  the  very  spot  where  the  penile  pain  is 
*  mostly  complained  of,  viz.,  at  the  posterior  part  of  the 
glans. 

The  nerve  relations  between  the  anus  and  the  neck 
of  the  bladder  are  very  intimate.  Painful  affections  of 
the  anus  often  cause  bladder  troubles,  and  retention 
of  urine  is  very  common  after  operations  upon  piles. 
Maladies,  on  the  other  hand,  that  involve  the  bladder 
neck  are  often  associated  with  tenesmus  and  anal  dis- 
comfort. This  relation  is  maintained  by  the  pelvic 
plexus,  but  mainly  by  the  fourth  sacral  nerve.  This 
nerve  gives  special  branches  direct  to  the  neck 
of  the  bladder,  and  then  goes  to  supply  the  muscles  of 
the  anus  (the  sphincter  and  ievator)  and  the  integu- 
ment between  the  anus  and  the  coccyx. 

The  mucous  membrane  of  the  urethra,  the  muscles 
of  the  penis,  and  the  greater  part  of  the  skin  of  the 
penis,  scrotum,  perineum,  and  anus,  are  supplied  by  the 
pudic  nerve.  Thus,  it  will  be  understood  that  irritation 
applied  to  the  urethra  may  cause  erection  of  the  penis 
(as  illustrated  by  chordee  in  gonorrhosa),  or  may  pro- 
duce contraction  of  the  urethral  muscles  (as  seen  in 
some  forms  of  spasmodic  stricture).  The  disturbance 
caused  by  accumulated  secretion  beneath  the  prepuce 
in  young  children  may  provoke  great,  irritability  of  the 


chap,  xviii.]      PELVIS  AND  PERINEUM.  423 

organ,  and  it  is  well  known  that  painful  affections  of 
the  perineum  and  anus  may  be  associated  with 
priapism.  The  presence  of  the  inferior  pudendal 
nerve  in  the  perineum  will  explain  the  pain  about  the 
buttock  and  down  the  back  of  the  thigh  that  is  often 
complained  of  during  the  growth  of  perineal  abscess 
and  in  painful  affections  of  the  scrotum.  This  nerve 
crosses  just  in  front  of  the  tuber  ischii,  and  may  be 
so  pressed  upon  by  using  a  hard  seat  as  to  cause  one- 
sided neuralgia  of  the  penis  and  scrotum.  It  is  also 
in  close  connection  with  the  ischial  bursa,  and  neu- 
ralgia of  the  same  parts  has  been  met  with  in  cases  of 
inflammation  involving  that  structure. 

The  testicle  is  supplied  mainly  by  the  spermatic 
plexus.  This  plexus  comes  off'  from  the  renal, 
and  thus  the  testicle  is  brought  into  close  relation  with 
the  kidney.  This  is  illustrated  by  the  pain  felt  in  the 
renal  region  in  neuralgia  of  the  testicle,  by  the  pain 
felt  in  the  testicle,  and  by  the  vigorous  retraction  of 
that  organ  observed  in  certain  affections  of  the  kidney, 
such  as  in  acute  nephritis,  and  in  the  passage  of  renal 
calculi.  By  means  of  the  renal  plexus  the  testicle  is 
brought  into  direct  communication  with  the  semi- 
lunar  ganglia  and  solar  plexus.  This  communication 
serves  to  explain  the  great  collapse  often  noticed  in 
sudden  injuries  to  the  testicle,  and  especially  the 
marked  tendency  to  vomit,  so  often  observed  in  such 
lesions.  So  far  as  its  nerves  arc  concerned,  the  testicle 
is  nearly  in  as  intimate  relation  with  the  great  nerve- 
centre  of  the  abdomen  as  is  a  great  part  of  the  small 
intestine,  and  one  would  expect  a  sudden  crush  of  the 
testis  to  be  associated  with  as  sevei'e  general  symptoms 
as  would  accompany  a  sudden  nipping  of  the  ileum 
in  a  rupture.  Such  a  resemblance  in  symptoms  is 
Actually  to  be  observed  in  practice, 


424 


liatt  17. 

THE    LOWER   EXTREMITY. 


CHAPTER   XIX. 

THE    REGION    OF    THE    HIP. 

THIS  region  will  be  considered  under  the  following 
heads :  1.  The  buttocks.  2.  The  region  of  Scarpa's 
triangle.  3.  The  hip  joint.  4.  The  upper  third  of 
the  femur. 

1.  The  buttocks.  —  Surface  anatomy. — The 
bony  points  about  the  gluteal  region  can  be  well 
made  out.  The  crest  of  the  ilium  is  distinct,  as  is  also 
the  anterior  superior  spine.  The  posterior  superior 
spine  is  less  evident,  but  can  be  readily  felt  by  follow- 
ing the  crest  to  its  posterior  termination.  This  spine 
is  on  a  level  with  the  second  sacral  spine,  and  is 
placed  just  behind  the  centre  of  the  sacro-iliac  articu- 
lation. The  great  trochanter  is  a  conspicuous  land- 
mark. It  is  covered  by  the  fascial  insertion  of  the 
glutens  maximus.  Its  upper  border  is  on  a  level  with 
the  centre  of  the  hip  joint,  and  is  somewhat  obscured 
by  the  tendon  of  the  gluteus  medius  which  passes  over 
it.  The  comparatively  slight  prominence  of  the  tro- 
chanl.er  in  the  living  subject,  as  compared  with  the  great 
projection  it  forms  in  the  skeleton,  depends  upon  the 
completeness  with  which  the  gluteus  medius  and 
minimus  fill  up  the  hollow  between  the  trochanter  and 
the  ilium.  When  these  muscles  are  atrophied  the 
process  becomes  very  conspicuous.  In  fat  individuals 


Chap,  xix.]  THE  BUTTOCK,  425 

its  position  is  indicated  by  a  slight  but  distinct  depres- 
sion over  the  hip. 

If  a  line  be  drawn  from  the  anterior  superior  spine 
to  the  most  prominent  part  of  the  tuber  ischii,  it  will 
cross  the  centre  of  the  acetabulum,  and  will  hit  the  top 
of  the  trochanter.  This  line,  known  as  Nelaton's  line, 
is  frequently  made  use  of  in  the  diagnosis  of  certain 
injuries  about  the  hip.  For  like  diagnostic  purposes 
Bryant  makes  use  of  a  "  triangle."  As  the  patient  lies 
in  the  recumbent  posture,  a  vertical  line  is  dropped 
from  the  anterior  superior  spine.  A  second  line  is 
drawn  forwards  from  the  same  point  to  the  top  of  the 
great  trochanter.  The  triangle  is  completed  by  a  third 
line  joining  the  first  two,  and  drawn  at  right  angles 
to  the  vertical  line.  A  measurement  of  this  third  or 
test  line  will  show  if  any  shortening  has  taken  place 
in  the  neck  of  the  femur.  It  may  be  noted  that  the 
top  of  the  trochanter  is  nearly  on  a  level  with  the 
pubes. 

The  tubera  ischii  are  readily  felt.  They  are  covered 
by  the  fleshy  fibres  of  the  gluteus  maximus  when  the 
hip  is  extended.  But  when  the  hip  is  flexed,  the  pro- 
cesses become  to  a  great  extent  uncovered  by  that 
muscle.  The  muscular  mass  of  the  buttock  is  formed 
by  the  gluteus  maximus  behind  and  by  the  gluteus 
medius  and  minimus  and  tensor  vaginae  femoris  in 
front.  The  latter  muscle  can  be  seen  when  in  action, 
i.e.,  when  the  thigh  is  abducted  and  rotated  in. 

The  fold  of  the  buttock  is  considerably  above  the 
level  of  the  lower  border  of  the  gluteus  maximus,  with 
which  it  therefore  does  not  correspond.  When  the 
hip  is  fully  extended,  as  in  the  erect  posture,  the  but- 
tocks are  round  and  prominent,  the  gluteal  fold  is  trans- 
verse and  very  distinct.  When  the  hip  is  a  little  flexed, 
the  buttocks  become  flattened,  the  gluteal  fold  be- 
comes oblique,  and  to  a  large  extent  disappears.  Among 
the  early  symptoms  of  hip  disease  are  flattening  of 


426  SURGICAL  APPLIED  ANATOMY.     [Chap.  xix. 

the  buttock  and  loss  of  the  gluteal  fold.  These 
symptoms  depend  upon  the  Hexion  of  the  hip,  which  is 
practically  constant  in  every  case  of  the  malady  before 
treatment.  It  is  incorrect  to  say,  as  some  books 
still  assert,  that  these  changes  are  due  to  wasting  of 
the  gluteal  muscles,  since  they  appear  at  too  early 
a  period  for  any  considerable  muscular  atrophy  to 
have  taken  place.  It  is  true  that  these  symptoms 
are  much  exaggerated  by  the  wasting  of  the  muscle 
that  occurs  later  on  in  the  course  of  the  hip  affection. 

With  regard  to  the  vessels  and  nerves  of  the  but- 
tock, if  a  line  be  drawn  from  the  posterior  superior 
spine  to  the  top  of  the  great  trochanter  when  the  thigh 
i»  rotated  in,  a  point  at  the  junction  of  the  inner  with 
the  middle  third  of  that  line  will  correspond  to  the 
gluteal  artery  as  it  emerges  from  the  sciatic  notch. 
A  line  drawn  from  the  posterior  superior  spine  to  the 
outer  part  of  the  tuber  ischii  crosses  both  the  posterior 
inferior  and  ischial  spines.  The  former  is  about 
two  inches  and  the  latter  about  four  inches  below 
the  posterior  superior  process.  The  sciatic  artery 
reaches  the  gluteal  region  at  a  spot  corresponding  to 
the  junction  of  the  middle  with  the  lower  third  of  this 
line.  The  position  of  the  pudic  artery  as  regards  the 
buttock  is  not  difficult  to  indicate,  since  it  crosses  over 
the  ischial  spine  in  passing  from  the  great  to  the  small 
sacro-sciatic  foramen. 

A  line  drawn  from  the  point  just  given  for 
the  sciatic  artery  down  the  back  of  the  limb,  so  as  to 
lie  about  midway  between  the  great  trochanter  and  the 
ischial  tuberosity,  will  correspond  to  the  course  of  the 
great  sciatic  nerve. 

The  skin  over  the  buttock  is  thick  and  coarse, 
and  is  frequently  the  seat  of  boils.  From  the  appear- 
ance it  presents  in  very  fully  injected  specimens,  it 
would  appear  that  its  blood  supply  is  not  quite  so  free 
as  it  is  in  many  other  parts  of  the  surfa.ce. 


chap,  xix.]  THE  BUTTOCK.  427 

The  subcutaneous  fascia  is  lax,  and  contains  a  large 
quantity  of  fat.  It  is  to  this  fat  rather  than  to  mus- 
cular development  that  the  buttock  owes  its  roundness 
and  prominence.  The  enormous  buttocks  of  the  so- 
called  "  Hottentot  Venus,"  whose  model  is  in  many 
museums,  depend  for  their  unusual  dimensions  upon 
the  greatly  increased  subcutaneous  fat.  The  amount 
of  adipose  tissue  normally  in  the  part  renders  the 
bxittock  a  favourite  place  for  lipomata.  The  laxity  of 
the  superficial  fascia  permits  large  effusions  both  of 
blood  and  pus  to  take  place  in  the  gluteal  region,  and 
ecchymoses  of  the  buttock  can  probably  reach  a  greater 
magnitude  than  is  possible  elsewhere. 

The  deep  fascia  of  the  buttock,  a  part  of  the 
fascia  lata  of  the  thigh,  is  a  structure  of  much 
importance.  This  dense  membrane  is  attached  above 
to  the  iliac  crest,  and  to  the  sacrum  and  coccyx. 
Descending  in  front  over  the  gluteus  medius,  it  splits 
on  reaching  the  anterior  edge  of  the  gluteus  maximus 
into  two  layers,  one  of  which  passes  in  front  of  the 
muscle  and  the  other  behind.  The  gluteus  maximus 
is  thus  enclosed,  like  the  meat  in  a  sandwich,  between 
two  layers  of  fascia,  and  the  two  lesser  gluteal  muscles 
are  bound  down  within  an  osseo-aponeurotic  space, 
which  is  firmly  closed  above,  and  only  open  below 
towards  the  thigh,  and  internally  at  the  sciatic 
foramina.  Extravasations  of  blood  may  take  place 
beneath  this  fascia  without  any  discoloration  of  the 
skin  to  indicate  the  fact,  the  blood  being  unable  to 
reach  the  surface  through  the  dense  membrane.  Such 
extravasations  may  be  long  pent  up,  and,  as  they 
would  fluctuate,  may  be  mistaken  for  abscess. 

Deep  inflammations  beneath  this  fascia,  and 
especially  when  beneath  the  gluteus  medius,  may  be 
associated  with  much  pain,  owing  to  the  circumstance 
that  the  inflammatory  effusions  will  be  pent  up  between 
a  wall  of  bone  oil  cne  side  and  a  wall  of  dense  fascia 


428  SURGICAL  APPLIED  ANATOMY.     [Chap,  xix 

and  stout  muscle  on  the  other.  Abscesses  so  pent  up 
may  travel  for  a  considerable  distance  down  the  thigh 
before  they  reach  the  surface,  and  Farabeuf  relates  a 
case  where  a  gluteal  abscess  travelled  to  the  ankle 
before  it  broke. 

Under  other  circumstances  the  gluteal  abscess  may 
make  its  way  into  the  pelvis  through  the  sciatic 
foramina,  or  a  pelvic  abscess  may  escape  through  one 
of  these  foramina,  and  appear  as  a  deep  abscess  of  the 
buttock. 

The  thickened  part  of  the  fascia  lata  that  runs 
down  on  the  outer  side  of  the  limb,  between  the  crest 
of  the  ileum  above  and  the  outer  tuberosity  of  the 
tibia  and  head  of  the  fibula  below,  is  known  as  the 
ilio-tibial  band.  This  band  is  tightly  stretched  across 
the  gap,  between  the  iliac  crest  and  the  great 
trochanter,  and  if  pressure  be  made  with  the  fingers 
between  these  two  points,  the  resistance  of  this  part 
of  the  fascia  can  be  appreciated.  It  is  obvious  that 
in  fracture  of  the  neck  of  the  femur,  when  the  great 
trochanter  is  made  to  approach  nearer  to  the  crest, 
this  band  will  become  relaxed,  and  Dr.  Allis  (Agnew's 
"Surgery,"  voL  L)  has  drawn  attention  to  this  fascial 
relaxation  as  of  value  in  the  diagnosis  of  fractures  of 
the  femoral  neck. 

The  lower  free  edge  of  the  glutens  maximus  is 
oblique,  and  is  some  way  below  the  transverse  line  of 
the  fold  of  the  buttock. 

It  would  appear  that  even  this  great  muscle  may 
be  ruptured  by  violence.  Thus  Dr.  MacDonnell  (Brit. 
Med.  Journ.,  1878)  reports  the  case  of  a  robust  man, 
aged  sixty-three,  who,  while  trying  to  lift  a  heavy 
cart  when  in  a  crouching  position,  felt  something 
give  way  in  his  buttock,  and  heard  a  snap.  He  fell, 
and  was  carried  home,  when  it  was  found  that  the 
great  gluteal  muscle  was  ruptured  near  the  junction 
with  its  tendon. 


chap,  xix.]  THE  BUTTOCK.  429 

At  least  three  fonrsae  exist  over  the  great 
trochanter,  separating  that  process  from  the  three 
gluteal  muscles  respectively.  The  most  important  of 
these  is  the  bursa  between  the  gluteus  maximus  and 
the  bone.  When  this  sac  is  inflamed  much  difficulty 
is  experienced  in  moving  the  limb,  and  the  thigh  is 
generally  kept  flexed  and  adducted.  This  position 
means  absolute  rest  from  movement  on  the  part  of  the 
gluteal  muscles,  which,  when  acting,  would  extend 
and  abduct  the  limb,  and  bring  pressure  to  bear  upon 
the  tender  bursa. 

The  bursa  is  quite  close  to  the  bone,  so  close  that 
it  is  said  that  caries  of  the  trochanter  has  followed 
upon  suppuration  of  the  little  sac  (T.  P.  Teale). 
There  is  a  bursa  over  the  ischial  tuberosity  that  is 
often  inflamed  in  those  whose  employments  involve 
much  sitting,  the  bursa  being  directly  pressed  upon  in 
that  position.  This  sac  is  the  anatomical  basis  of 
the  disease  known  in  older  text-books  as  "  weaver's 
bottom,"  or  "  lighterman's  bottom."  When  enlarged 
this  bursa  may  press  upon  the  inferior  pudendal  nerve 
(page  384). 

The  arteries  and  nerves  of  the  buttock. — 
The  gluteal  artery  is  about  the  same  size  as  the  ulnar, 
and  the  sciatic  as  the  lingual.  The  former  vessel 
may  sometimes  be  of  much  greater  magnitude,  and 
has  led,  when  wounded,  to  rapid  death  from  haemorr- 
hage. Wounds  of  the  gluteal  vessel  will  probably 
involve  only  the  branches  of  the  artery,  since  the 
greater  part  of  the  main  trunk  is  situate  within  the 
pelvis.  Gluteal  aneurisms  are  not  very  uncommon, 
and  with  regard  to  the  treatment  of  these  tumours  it 
may  be  noted  that  the  gluteal  artery,  or,  better,  the 
internal  iliac  trunk,  can  be  compressed  through  the 
rectum.  Compression  so  applied  has  been  adopted 
for  the  treatment  of  gluteal  aneurism  by  Dr.  Sands 
of  New  York  (Amer.  Journ.  Med.  Sc.,  1881),  but 


43^  SURGICAL  APPLIED  ANATOMY.     [Chan.  xix. 

without  much  effect.  Aneurism  of  the  commence- 
ment of  the  gluteal  artery  could  hardly  fail  to  provoke 
nerve  symptoms,  since  the  vessel  runs  between  the 
lumbo-sacral  cord  and  first  sacral  nerve. 

Both  the  gluteal  and  sciatic  arteries  have  been 
ligatured  through  the  buttock,  through  incisions  made 
directly  over  the  course  of  the  vessels. 

Henle  has  collected  six  cases  where  the  femoral 
artery  ran  down  along  the  back  of  the  thigh  to  the 
popliteal  space  in  company  with  the  great  sciatic 
nerve.  The  abnormal  vessel  was  in  each  case  con- 
tinued from  a  greatly  enlarged  sciatic  artery. 

The  great  sciatic  nerve  is  a  continuation 
downwards  of  the  main  part  of  the  sacral  plexus.  It 
is  in  this  nerve  that  the  form  of  neuralgia  known 
as  sciatica  is  located.  A  reference  to  the  immediate 
relations  of  this  nerve  will  show  that  it  may  readily 
be  exposed  to  many  external  influences.  Thus,  in  the 
pelvis  it  may  be  pressed  upon  by  various  forms  of 
pelvic  tumour,  and  sciatica  be  produced  in  consequence. 
Its  anterior  surface  is  in  close  relation  with  some  of 
the  principal  pelvic  veins,  and  according  to  Erb  one 
form  of  sciatica  may  be  traced  to  an  engorged  condition 
of  these  vessels.  Aneurism  of  certain  branches  of  the 
internal  iliac  artery  within  the  pelvis,  sciatic  hernia, 
and  accumulation  of  faeces  within  the  rectum,  may  all 
cause  neuralgia  of  this  important  trunk.  It  is  said  to 
have  been  injured  also  by  the  pressure  of  the  festal 
head  during  tedious  labours,  and  to  be  affected  by 
violent  movements  of  the  hip,  a  circumstance  readily 
understood  if  the  close  relation  of  the  nerve  to  the 
hip-joint  be  borne  in  mind.  The  nerve  is  also  near 
enough  to  the  surface  to  be  influenced  by  external 
cold,  and  to  this  influence  many  forms  of  sciatica  are 
ascribed.  At  the  lower  edge  of  the  great  gluteal 
muscle  the  trunk  is  still  nearer  to  the  surface,  and 
this  fact  receives  illustration  in  a  case  reported  in 


Chap,  xtx.]  THE  BUTTOCK.  431 

Ziemssen's  Cyclopaedia,  where  paralysis  of  the  nerve 
followed  its  compression  by  the  contracting  scar  of  a 
bed-sore. 

Nerve  stretching. — The  great  sciatic  nerve  has 
been  frequently  cut  down  upon  and  roughly  stretched 
for  the  relief  of  certain  nervous  affections  of  the  lirnb. 
In  connection  with  this  procedure  it  is  important 
to  know  how  great  an  amount  of  traction  may  be 
brought  to  bear  upon  this  and  other  nerves  without 
the  cord  giving  way.  Trombetta,  who  has  paid  much 
attention  to  this  matter,  gives  the  following  weights 
as  those  required  to  break  the  undermentioned  nerves  : 
great  sciatic,  183  pounds;  internal  popliteal,  114 
pounds ;  anterior  crural,  83  pounds ;  median,  83 
pounds;  ulnar  and  radial,  59  pounds;  brachial 
plexus  in  the  neck,  48  to  63  pounds ;  and  brachial 
plexus  in  the  axilla,  35  to  81  pounds.  (In  each 
instance  fractions  have  been  omitted.)  It  must 
be  borne  in  mind,  however,  as  pointed  out  by  Mr. 
Symington  (Lancet,  1878),  that  in  forcibly  stretching 
the  great  sciatic  nerve  the  trunk  may  be  torn  away 
from  its  attachments  to  the  soft  spinal  cord  before  a 
sufficient  force  has  been  applied  to  rupture  the  nerve 
at  the  point  stretched.  The  same  observation  applies 
to  other  large  nerve-cords,  such  as  those  of  the  brachial 
plexus,  that  are  stretched  at  a  spot  not  far  from  their 
spinal  connections. 

The  skin  of  the  buttock  is  well  supplied  with 
nerves,  and  tactile  sensibility  is  almost  as  acute  in 
this  part  as  it  is  over  the  back  of  the  hand,  while  it  is 
more  acute  than  is  like  sensibility  in  such  parts  as 
the  back  of  the  neck,  the  middle  of  the  thigh,  and  the 
middle  of  the  back.  The  sensation  of  the  gluteal 
integument  is  derived  from  a  number  of  different 
nerves,  and  it  may  possibly  interest  a  school-boy,  who 
has  been  recently  birched,  to  know  that  the  painful 
sensations  reached  his  sensorium  through  some  or  all 


432  SURGICAL  APPLIED  ANATOMY.     [Chap,  xix 

of  the  following  nerves :  offsets  of  the  posterior 
branches  of  the  lumbar  nerves,  some  branches  of  the 
sacral  nerves,  the  lateral  cutaneous  branch  of  the  last 
dorsal  nerve,  the  iliac  branch  of  the  ilio-hypogastric 
nerve,  offsets  of  the  external  cutaneous  nerve,  and 
large  branches  of  the  small  sciatic. 

It  should  be  remembered  that  the  pelvic  viscera 
can  be  readily  reached  through  the  sciatic  foramina 
from  the  buttock.  I  once  saw  a  case  at  the  London 
Hospital  of  a  man  who  was  admitted  with  an 
apparently  insignificant  stab  of  the  buttock.  He  died 
in  a  few  days,  of  acute  peritonitis  ;  and  the  autopsy 
showed  that  the  dagger  had  passed  through  the  gi-eat 
sacro-sciatic  foramen,  had  entered  the  bladder  and 
allowed  urine  to  escape  into  the  peritoneal  cavity. 
The  rectum  has  also  been  damaged  in  injuries  to  the 
buttock,  and  Anger  records  a  case  of  an  artificial  anus 
situate  upon  the  buttock,  that  had  followed  a  gunshot 
wound,  which,  after  involving  the  buttock,  had  opened 
up  the  caecum. 

2.  The  region  of  Scarpa's  triangle.— 
Surface  anatomy. — The  most  important  land- 
marks in  the  region  of  the  groin,  the  anterior  superior 
iliac  spine,  the  spine  of  the  pubes,  and  Poupart's 
ligament,  arfi  readily  made  out.  To  the  two  spines 
reference  has  already  been  made  (page  288).  Poupart's 
ligament  follows  a  curved  line,  with  its  convexity  down- 
wards, drawn  between  these  two  projections.  It  can 
be  felt  in  any  but  stout  persons,  its  inner  half  more 
distinctly  than  its  outer,  and  even  in  very  fat  indivi- 
duals its  position  is  indicated  by  a  slight  furrow.  The 
ligament  is  relaxed,  and  rendered  less  distinct  when 
the  thigh  is  flexed  and  adducted,  or  when  it  is 
rotated  in. 

The  line,  often  called  "  Holden's  line,"  is  thus 
described  by  that  surgeon  :  "  When  the  thigh  is  even 
slightly  bent,  there  appears  a  second  furrow  in  the 


chap,  xix.]  SCARPA'S  TRIANGLE.  433 

skin,  below  that  at  the  crural  arch.  This  second 
furrow  begins  at  the  angle  between  the  scrotum  and 
the  thigh,  passes  outwards,  and  is  gradually  lost 
between  the  top  of  the  ti'ochanter  and  the  anterior 
superior  spine  of  the  ilenm.  It  runs  right  across  the 
front  of  the  capsule  of  the  hip-joint.  For  this  reason 
it  is  a  valuable  landmark  in  amputation  at  the  hip- 
joint.  The  point  of  the  knife  shoxild  be  introduced 
externally  where  the  furrow  begins,  should  run 
precisely  along  the  line  of  it,  and  come  out  where  it 
ends  ;  so  that  the  capsule  of  the  joint  may  be  opened 

with  the  first  thrust Eft'usion  into  the  joint 

obliterates  all  trace  of  the  furrow,  and  makes  a 
fulness  when  contrasted  with  the  opposite  groin." 
It  must  be  confessed  that  this  line  is  not  always  so 
distinct  as  Mr.  Holden's  description  would  lead  us  to 
believe,  and  in  many  subjects  it  is  quite  impossible  to 
make  it  out  at  all. 

The  sartorius  muscle  is  brought  into  view  when 
the  leg  is  raised  across  the  opposite  knee,  and  the 
adductor  longus  is  rendered  distinct  when  the  thigh 
is  abducted,  and  the  individual's  attempts  to  adduct 
the  limb  are  resisted.  Even  in  the  obese  the  clear 
edge  of  this  muscle  can  be  felt  when  it  is  in  vigorous 
action,  and  the  fingers  can  follow  its  border  up  to 
the  very  origin  of  the  muscle,  just  below  the  pubic 
spine. 

The  lymphatic  glands  in  this  region  can  sometimes 
be  felt  beneath  the  skin,  especially  in  thin  children. 
The  femoral  ring  lies  on  a  horizontal  line  drawn  from 
the  pubic  spine  to  the  top  of  the  great  trochanter,  at 
about  one  inch  to  the  outer  side  of  the  first-named 
process;  or  its  position  may  be  indicated  by  noting  the 
pulsations  of  the  femoral  artery  against  the  pubes ; 
and  then,  by  allowing  half  an  inch  to  the  inner  side  of 
that  vessel  for  the  femoral  vein,  the  site  of  the  femoral 
ring  will  be  reached.  The  position  of  the  saphenoui 
CO — 4 


434  SURGICAL  APPLIED  ANATOMY.     [Chap.  xix. 

opening  is  sometimes  indicated  by  a  slight  depression 
in  the  integuments.  It  lies  just  below  Poupart's 
ligament,  and  its  centre  is  about  one  and  a  half  inches 
below  and  external  to  the  pubic  spine.  In  thin 
subjects  the  long  saphenous  vein  can  be  often  made 
out,  passing  to  the  saphenous  opening. 

If  a  line  be  drawn  from  a  point  just  to  the  inner 
side  of  the  middle  of  Poupart's  ligament  to  the  tubei'cle 
for  the  adductor  niagnus,  on  the  inner  condyle  of  the 
femur,  it  will  correspond  in  the  upper  two-thirds  of 
its  extent  to  the  position  of  the  femoral  artery.  Just 
below  Poupart's  ligament  the  femoral  vein  lies  to  the 
inner  side  of  the  artery,  while  the  anterior  crural 
nerve  runs  about  one-fourth  of  an  inch  to  its  outer 
side.  The  profunda  fernoris  arises  about  one  and  a 
half  inches  below  Poupart's  ligament,  and  the  internal 
and  external  circumflex  vessels  come  off  about  two 
inches  below  that  structure. 

The  head  of  the  femur  lies  close  below  the 
ligament,  and  just  to  the  outer  side  of  its  central 
point.  In  very  thin  subjects  this  part  of  the  bone 
can  be  indistinctly  felt  through  the  soft  parts  when 
the  thigh  is  extended  and  rotated  outwards. 

The  skin  over  Scarpa's  triangle  is,  unlike  that  of 
the  buttock,  comparatively  thin  and  fine.  The  loose- 
ness of  its  attachment,  also,  to  the  parts  immediately 
beneath,  permits  it  to  be  greatly  stretched,  as  is  seen 
in  cases  of  large  femoral  herniae,  and  in  certain  inguinal 
tumours  of  large  size.  It  may  even  give  way  under 
severe  traction,  as  occurred  in  a  case  reported  by 
Berne.  The  patient  in  this  case  was  a  child  aged  11, 
the  subject  of  hip  disease.  The  thighs  were  flexed 
upon  the  abdomen,  and,  forcible  extension  being 
applied  to  relieve  the  deformity,  the  skin  gave  way 
just  below  the  groin,  and  separated  to  the  extent  of 
some  two  and  a  half  inches.  Contracting  scars  in  the 
region  of  the  groin  may  produce  a  permanent  flexing 


Chap,  xix]  SCARPA'S  TRIANGLE.  431; 

of  the  hip,  and  this  result  is  not  uncommon  after  deep 
and  severe  burns  of  this  neighbourhood.  It  may  at 
the  same  time  be  noted  that  horizontal  wounds  about 
the  groin  can  be  well  adjusted  by  a  slight  flexion  of 
the  thigh. 

Instances  are  recorded  where  a  supernumerary 
mammary  gland,  provided  with  a  proper  nipple,  has 
been  found  located  in  the  groin.  Jessieu  relates  the 
case  of  a  female  who  had  a  breast  so  placed,  and  who 
suckled  her  child  from  this  part.  In  a  few  cases  the 
testicle,  instead  of  descending  into  the  scrotum,  has 
escaped  through  the  crural  canal,  and  made  its 
appearance  in  Scarpa's  triangle.  It  has  even  mounted 
up  over  Poupart's  ligament  after  the  manner  of  a 
femoral  hernia,  being  probably  urged  in  that  direction 
by  the  movements  of  the  limb. 

The  superficial  fascia  in  this  region  is  not 
very  dense,  and  has  little  or  mr  influence  upon  the 
progress  of  a*  superficial  abscess.  This"fact  receives 
extensive  illustration,  since  the  glands  in  Scarpa's 
triangle  frequently  suppurate,  and  yet  the  pus  in  the 
great  majority  of  the  cases  readily  reaches  the  surface, 
in  spite  of  the  circumstance  that  the  denser  layer  of  the 
superficial  fascia  (for  in  tliis- region  it  is  divided  into 
two  layers)  covers  in  those  glands,  and  should  hinder 
the  progress  of  pus  towards  the  surface.  Although 
the  subcutaneous  fat  is  not  peculiarly  plentiful  in  this 
region,  yet  Scarpa's  triangle  is  a  favourite  spot  for 
lipomata.  It  is  in  this  place  that  the  fatty  tumour 
often  exhibits  its  disposition  to  travel,  and  several 
cases  are  reported  where  such  a  tumour  has  started  at 
the  groin,  and  travelled  some  way  down  the  thigh. 
The  journey  is  always  in  the  direction  of  gravity,  and 
is  rendered  possible  by  the  lax  capsule  of  the  tumour, 
by  the  looseness  of  the  tissue  in  which  it  is  embedded, 
and  by  the  fluidity  of  fat  at  the  normal  temperature 
of  the  body. 


436  SURGICAL  APPLIED  ANATOMY.     [Chap.  xix. 

The  fascia  lata  completely  invests  the  limb, 
being,  so  far  as  the  front  of  the  thigh  is  concerned, 
attached  above  to  Poupart's  ligament,  to  the  body  and 
ramus  of  the  pubes,  and  the  ramus  of  the  ischium. 
Its  integrity  is  interrupted  only  by  the  saphenous 
opening.  This  fascia  exercises  some  influence  upon 
deep  abscesses  and  deep  growths.  Thus  a  psoas 
abscess  reaches  the  thigh  by  following  the  substance 
of  the  psoas  muscle,  and  finds  itself,  when  it  arrives  at 
Scarpa's  triangle,  under  the  fascia  lata.  In  a  great 
number  of  cases  it  points  where  the  psoas  muscle 
ends,  but  in  other  and  less  frequent  instances  its 
progress  is  decidedly  influenced  by  the  fascia  lata,  and 
it  moves  down  the  limb.  Thus  guided,  a  psoas 
abscess  has  pointed  low  down  in  the  thigh,  and  even 
at  the  knee,  and  Erichsen  reports  a  case  where  such 
an  abscess  (commencing,  as  it  did,  in  the  dorsal  spine), 
was  ultimately  opened  by  the  side  of  the  tendo 
Achillis. 

The  ilio-psoas  muscle  being  stretched,  as  it  were, 
over  the  front  of  the  hip  joint,  and  participating  in 
many  of  the  movements  of  that  joint,  is  peculiarly 
liable  to  be  sprained  in  violent  exercises.  Between 
this  muscle  and  the  thinnest  part  of  the  hip  capsule  is 
a  bursa,  which  often  communicates  with  the  joint. 
When  chronically  inflamed,  this  bursa  may  form  a  large 
tumour  on  the  front  of  the  thigh  that  may,  accord- 
ing to  Kancrede,  attain  the  size  of  a  child's  head.  To 
relieve  this  bursa  from  pressure  when  inflamed,  the 
thigh  always  becomes  flexed,  and  a  train  of  symptoms 
is  produced  that  are  not  unlike  those  of  hip  disease. 
The  bursa  is  quite  close  to  the  pelvic  bones,  and  in  one 
case  at  least  suppuration  of  this  bursa  led  to  necrosis 
of  those  bones  (Nancrede).  The  sartorius  is  a  muscle 
that,  from  its  length,  peculiar  action,  etc.,  one 
would  hardly  expect  to  find  ruptiired  from  violence, 
yet  in  the  Musee  Dupuytren  there  is  a  specimen  of  such 


Chap.  XIX.]  SCARPA'S  TRIANGLE.  437 

a  rupture  about  the  middle  of  the  muscle  united  by 
fibrous  tissue.  The  adductor  muscles,  and  especially 
the  adductor  longus,  are  frequently  sprained  or  even 
partially  ruptured  during  horse  exercise,  the  grip  of 
the  saddle  being  for  the  most  part  maintained  by 
them.  "Rider's  sprains,"  as  such  accidents  are 
called,  usually  involve  the  muscles  close  to  their  pelvic 
attachments.  Much  blood  is  often  effused  when  the 
fibres  are  ruptured,  and  such  effusion  may  become 
so  dense  and  fibrinous  as  to  form  a  mass  that  has 
been  mistaken  for  a  detached  piece  of  the  pubes 
(Henry  Morris).  The  term  "  rider's  bone  "  refers  to 
an  ossification  of  the  upper  tendon  of  the  adductor 
longus  or  magnus,  following  a  sprain  or  partial 
ruptura  Cases  are  reported  where  the  piece  of  bone 
in  the  tendon  was  half  an  inch,  two  inches,  and  even 
three  inches  long. 

Blood-vessels. — The  femoral  artery  occupies  so 
superficial  a  position  in  Scarpa's  triangle,  that  it  is  not 
infrequently  wounded.  The  vessel  also  has  been 
opened  up  by  cancerous  and  phagedsenic  ulcerations  of 
this  part,  the  occurrence  leading  to  fatal  haemorrhage. 
Pressure  is  most  conveniently  applied  to  the  artery  at 
a  spot  immediately  below  Pou part's  ligament,  and 
should  be  directed  backwards,  so  as  to  compress  the 
vessel  against  the  pubes  and  adjacent  part  of  the  hip 
capsule.  Lower  down,  compression  should  be  applied 
in  a  direction  backwards  and  outwards,  so  as  to  bring 
the  artery  against  the  shaft  of  the  femur,  which  lies 
at  some  distance,  to  its  outer  side.  Pressure  rudely 
applied  by  a  tourniquet  may  cause  phlebitis  by 
damaging  the  vein,  or  neuralgia  by  contusing  the 
anterior  crural  nerve. 

From  the  near  proximity  of  the  arteiy  and  vein, 
it  happens  that  arterio-venous  aneurisms  following 
wound  have  been  met  with  in  this  situation.  Aneu- 
rism is  frequent  in  the  common  femoral,  and  many 


438  SURGICAL  APPLIED  ANATOMY.     [Chap.  xix. 

reasons  can  be  given  why  that  vessel  should  be  attacked. 
It  is  just  about  to  bifurcate  into  two  large  trunks,  its 
superficial  position  exposes  it  to  injury,  it  is  greatly 
influenced  by  the  movements  of  the  hip,  and  its  coats 
may  even  be  damaged  by  those  movements,  if  excessive. 

Phlebitis  of  the  femoral  vein  has  in  many  cases 
followed  contusion  of  the  vessel  in  its  upper  or  more 
superficial  part,  and  a  like  result  has  even  followed 
from  violent  flexion  of  the  thigh.  The  long  saphenous 
vein  is  often  varicose,  and  one  form  of  the  varicosity 
is  said  to  depend  upon  constriction  of  the  vein  by  an 
unduly  narrow  saphenous  opening.  One  sometimes 
meets  with  cases  that  may  probably  be  due  to  this 
cause  ;  but  the  evidence  is  not  sufficient  to  sanction 
the  operation  proposed  for  such  cases,  viz.  an  enlarge- 
ment of  the  saphenous  opening  itself.  That  varicose 
veins  are,  in  the  majority  of  cases,  of  congenital  origin 
is  now  very  generally  allowed. 

The  anterior  crural  nerve  lies  on  the  ilio-psoas 
muscle,  and  it  is  said  that  neuralgia  and  even 
paralysis  of  the  nerve  may  follow  upon  inflammation 
of  that  muscle  and  upon  psoas  abscess.  The  superficial 
position  of  the  trunk  exposes  it  to  injury.  Thegenito- 
crural  nerve  (the  nerve  that  supplies  the  cremaster 
muscle)  gives  a  sensory  filament  to  the  integument 
of  the  thigh  in  Scarpa's  triangle.  Irritation  of  the 
skin  over  the  seat  of  this  nerve,  which  is  placed  just 
to  the  outer  side  of  the  femoral  artery,  will  cause,  in 
children,  a  sudden  retractation  of  the  testicle.  The 
same  result  is  often  seen  in  adults,  also,  on  severer 
stimulation. 

The  lymphatic  glands  in  this  region  are 
numerous,  and  as  they  are  frequently  the  seat  of 
abscess,  it  is  important  to  know  from  whence  they 
derive  their  efferent  vessels.  They  are  divided  into  a 
superficial  and  deep  set.  The  superficial  set,  averaging 
from  ten  to  fifteen  glands,  are  arranged  in  two  clusters, 


Chap,  xix.]  SCARPA'S  TRIANGLE  4.39 

one  parallel  and  close  to  Poupart's  ligament  (the 
horizontal  series),  the  other  parallel  and  close  to  the 
long  saphenous  vein  (the  vertical  series).  The  deep 
set,  about  four  in  number,  are  placed  along  the  femoral 
vein,  and  occupy  the  crural  canal. 

The  inguinal  glands  receive  the  following  ly  inphatics : 

Superficial  vessels  of  lower  limb  =  vertical  set  of 
superficial  glands. 

Superficial  vessels  of  lower  half  of  abdomen  = 
middle  glands  of  horizontal  set. 

Superficial  vessels  from  outer  surface  of  buttock  — 
external  glands  of  horizontal  set. 

From  inner  surface  of  buttock  -  internal  glands 
of  horizontal  set.  (A  few  of  these  vessels  go  to  the 
vertical  glands). 

Superficial  vessels  from  external  genitals  =  hori- 
zontal glands,  some  few  going  to  vertical  sfct.  s, 

Superficial  vessels  of  perineum  =  vertical  set. 

Deep  lymphatics  of  lower  limb  =  deep  set  of  glands. 

The  lymphatics  that  accompany  the  obturator, 
gluteal,  and  sciatic  arteries,  and  the  deep  vessels  of 
the  penis,  pass  to  the  pelvis  and  have  no  concern 
with  the  inguinal  glands. 

One  of  the  deep  glands  lies  in  the  crural  canal 
and  upon  the  septum  crurale.  Being  surrounded  by 
dense  structures,  it  is  apt  to  cause  great  distress  when 
inflamed,  and  great  pain  when  the  hip  is  moved.  In 
some  cases,  by  reflex  disturbance,  it  has  produced 
symptoms  akin  to  those  of  strangulated  hernia.  Some 
branches  of  the  anterior  crural  nerve  lie  over  the 
inguinal  lymph  glands,  and  SirB.  Brodie  reports  a  case 
in  which  these  blanches  were  stretched  over  two  en- 
larged glands,  like  strings  of  a  violin  over  its  bridge, 
BO  that  violent  pain  and  convulsive  movements  were 
set  up  in  the  limb. 

Elephantiasis  Arabum  is  more  common  in  the 
lower  limb  than  in  any  other  part,  and  leads  to  an 


440  SURGICAL  APPLIED  ANATOMY.     [Chap.  xix. 

enormous  increase  in  the  size  of  the  extremity  (Co- 
chin or  Barbadoes  leg).  Its  pathology  is  intimately 
concerned  with  the  crural  lymphatics.  "Elephantiasis 
appears  to  consist  primarily  in  an  inflammatory  hyper- 
plasia  of  the  cellular  elements  of  the  connective  tissue, 
in  connection  with  which  (according  to  Yirchow)  there 
is  reason  to  believe  that  the  roots  of  the  lymphatic 
vessels  are  specially  involved.  Inflammatory  over- 
growth of  the  elements  of  the  lymphatic  glands  next 
ensues,  with  obstruction  to  the  passage  of  lymph 
through  them.  Then  this  fluid  stagnates  in  the  lym- 
phatic vessels,  which  sometimes  dilate  even  to  their 
radicles  in  the  cutaneous  papillae,  and  accumulates  in 
,the  interstices  of  the  affected  tissues,  adding  to  their 
bulk,  and  at  the  same  time  stimulating  them  to  over- 
growth ....  In  some  cases  of  elephantiasis, 
especially  those  in  which  the  genital  organs  or  adjoin- 
ing parts  of  the  thigh  or  abdomen  are  implicated, 
groups  of  vesicles  appear  here  and  there  on  the  affected 
surface,  which  are  really  dilated  lymphatic  spaces,  and 
which,  on  rupturing  ....  discharge  consider- 
able quantities  (sometimes  several  pints  at  a  time)  of 
lymph  (Dr.  Bristowe). 

The  hip  joint. — The  hip  joint  is  an  articulation 
of  considerable  strength.  This  strength  depends  not 
only  upon  the  shape  af  the  articulating  bones,  which 
permits  of  a  good  ball  and  socket  joint  being  formed, 
but  also  upon  the  powerful  ligaments  that  connect 
them,  and  the  muscular  bands  that  directly  support 
the  capsule.  These  advantages,  however,  are  to  some 
extent  counterbalanced  by  the  immense,  leverage  that 
can  be  brought  to  bear  upon  the  femur,  and  the  nu- 
merous strains  and  injiiries  to  which  the  joint  is 
subjected,  as  the  sole  connecting  link  between  the 
trunk  and  the  lower  limb. 

The  acetabulum  is  divided  into  an  articular  and  a 
non-articular  part.  The  former  is  of  horse-shoe  shape, 


Chap,  xix.]  HIP  JOINT.  441 

and  varies  from  one  inch,  to  half  an  inch  in  width. 
The  bone  immediately  above  the  articular  area  is 
very  dense,  and  through  it  is  transmitted  the  superin- 
cumbent weight  of  the  trunk.  The  non-articular  part 
corresponds  to  the  area  enclosed  by  the  horse-shoe,  and 
is  made  up  of  very  thin  bone.  In  spite  of  its  thinness 
it  is  very  rarely  fractured  by  any  violence  that  may 
drive  the  femur  up  against  the  pelvic  bones,  since  no 
ordinary  force  can  bring  the  head  of  the  thigh-bone 
in  contact  with  this  segment  of  the  os  innominatum. 

Pelvic  abscesses  sometimes  make  their  way  into 
the  hip  joint  through  the  non-articular  part  of  the 
acetabulum,  and  an  abscess  in  the  kip  joint  may  reach 
the  pelvis  by  the  same  route.  But  both  such  circum- 
stances are  rare.  In  some  cases  of  destructive  hip 
disease  the  acetabulum  may  separate  into  its  three 
component  parts.  Up  to  the  age  of  puberty  these 
three  bones  are  separated  by  the  Y-shaped  cartilage. 
At  puberty  the  cartilage  begins  to  ossify,  and  by  the 
eighteenth  year  the  acetabulum  is  one  continuous  mass 
of  bone.  The  breaking  up  of  the  acetabulum  by  disease, 
therefore,  is  only  possible  before  that  year. 

The  manner  in  which  the  various  movements  at 
the  hip  are  limited  may  be  briefly  expressed  as  follows. 
Flexion,  when  the  knee  is  bent,  is  limited  by  the  con- 
tact of  the  soft  parts  at  the  groin,  and  by  some  part 
of  the  ischio  femoral  ligament ;  when  the  knee  is  ex- 
tended the  movement  is  limited  by  the  hamstring 
muscles.  Extension  is  limited  by  the  ilio-fenioral  or 
Y  ligament.  Abduction  by  the  pectineo-femoral 
ligament.  Adduction  of  the  flexed  limb  is  limited 
by  the  ligamentum  teres  and  ischio-femoral  ligament, 
and  of  the  extended  limb  by  the  outer  fibres  of  the 
ilio  femoral  ligament  and  upper  part  of  the  capsule. 
Rotation  outwards  is  resisted  by  the  ilio-femoral 
ligament,  and  especially  by  its  inner  part,  during 
extension,  and  by  the  outer  limb  of  that  ligament  and 


442  SURGICAL  APPLIED  ANATOMY.     [Chsp.  xix. 

the  ligamentum  teres  during  flexion.  Rotation  inwards 
is  limited  during  extension  by  the  ilio-femoral  ligament, 
and  during  flexion  by  the  ischio-femoral  ligament  and 
inner  part  of  the  capsule. 

Hip  joint  disease. — Owing  to  its  deep  position 
and  its  thick  covering  of  soft  parts,  this  articulation  is 
able  to  escape,  to  a  great  extent,  those  severer  injuries 
that  are  capable  of  producing  acute  inflammation  in 
other  joints.  Acute  synovitis  is  indeed  quite  rare  in  the 
hip,  and  the  ordinary  disease  of  the  part  is  of  a  dis- 
tinctly chronic  character.  It  follows  also,  from  the 
deep  position  of  the  articulation,  that  pus,  when  it  is 
formed  in  connection  with  disease,  remains  pent  up, 
and  is  long  before  it  reaches  the  surface.  Suppuration 
In  this  region,  therefore,  is  often  very  destructive. 
When  effusion  takes  place  into  the  joint,  the  swelling 
incident  thereto  will  first  show  itself  in  those  parts 
where  the  hip  capsule  is  the  most  thin.  The  thinnest 
parts  of  the  capsule  are  in  front  and  behind  ;  in  front, 
in  the  triangular  interval  between  the  inner  edge  of 
the  Y  ligament  and  the  pectineo-femoral  ligament, 
and  behind,  at  the  posterior  and  lower  part  of  the 
capsule.  It  is  over  these  two  districts  that  the 
swelling  first  declaims  itself  in  cases  of  effusion  into 
the  joint,  and  as  these  parts  are  readily  accessible  to 
pressure,  it  follows  that  they  correspond  also  to  the 
regions  where  tenderness  is  most  marked  and  is 
earliest  detected. 

In  chronic  hip  disease,  certain  false  positions  are 
assumed  by  the  affected  limb,  the  meaning  of  which 
it  is  important  to  appreciate.  These  positions  may 
be  arranged  as  follows,  according,  as  nearly  as  possible, 
to  their  order  of  appearing. 

(1)  The  thigh  is  flexed,  abducted,  and  a  little 
everted  ;  and  associated  with  this  there  is  (2)  apparent 
lengthening  of  the  limb  and  (3)  lordosis  of  the 
spine ;  (4^  the  thigh  is  adducted  and  inverted,  and 


Chap.  XI X.)  tflP^JoiNT.  443 

incident  to  this  there  is  (5)  apparent  shortening  of 
the  limb  ;  (6)  there  is  real  shortening  of  the  limb. 

1.  The   first    position    is  simply    the    posture   of 
greatest  ease.     It  depends  mainly  upon  the  effusion 
into  the  joint.       If  fluid  be  forcibly  injected  into  a 
hip  joint  the   thigh   becomes  flexed,    abducted,    and 
a   little  everted.      In  other   words,    the  articulation 
holds    the    most    fluid    when    the    limb   is   in    this 
position,  and  the  patient   places  it  there  to   relieve 
pain  by   reducing    the    tension    within    the   capsule 
to  a  minimum.     Flexion  is  the  most  marked  feature 
in  this  position.     Its  effect  is  pronounced.     It  relaxes 
the  main  part  of  the  Y  ligament,  which,  when  the 
limb  is  straight,  is  drawn  as  an  unyielding  band  across 
the  front  of  the  joint.     Abduction  relaxes  the  outer 
limb  of  this  ligament  and  the  upper  part  of  the  cap- 
sule.    Eversion  slightly  relaxes  the  inner  limb  of  the 
Y   ligament  and  the  ischio-femoral    ligament.       The 
latter  movement  is  the  least  marked,  since  eversion, 
even  in  the  flexed  position  of  the  joint,  is  resisted  by 
the  outer  part  of  the  Y  ligament.     Any  but  a  moderate 
degree  of  abduction  would  be  limited  by  the  pectineo- 
femoral  ligament,  especially  as  that  band  is  rendered 
most  tense  when  abduction  is  combined  with  flexion 
and  rotation  outwards. 

2.  The  apparent  lengthening  is  due  to  the  tilting 
down  of  the  pelvis  on  the  diseased  side,  and  is  the 
result  of  the  patient's  attempts  to  overcome  the  effects 
of  the  position  just  described.     The  limb  is  shortened 
by  flexion  and  abduction,  and  to  bring  the  foot  again 
to  the  ground  and  to  restore  the  natural  parallelism  of 
the  limbs,  the  pelvis  has  to  be  tilted  down  on  the  affected 
side.     Thus,   an    apparent    lengthening   is   produced, 
which  is  seen  when  the  patient  lies  upon  a  bed  and  the 
abduction  is  made  to  disappear.      Real  lengthening  of 
the  limb  can  scarcely  be  produced  by  the  effusion  into 
the  joint.     By  forcible  injection  into  the  joint  Braune 


444 


SURGICAL  APPLIED  ANATOMY,     [chap.  xix. 


could  only  separate  the   articulating  surfaces  about 

one-fifth  of  an  inch. 

3.   The     lordosis,    or     curving    forwards    of    the 

spine,  occurs  in  the  dorso-lumbar  region.     It  depends 

upon   the   flexion   of    the    limb,    and    is   the    result 

of  an  attempt  to  con- 
ceal that  false  posi- 
tion, or  at  least  to 
minimise  its  incon- 
veniences (Fig.  3 9 A). 
When  the  thigh  is 
flexed  at  the  hip  by 
disease,  the  lower 
limb  can  be  made  to 
appear  straight  by 
simply  bending  the 
spine  forwards  in  the 
dorso  -  lumbar  region 
without  effecting  the 
least  movement  at  the 
disordered  joint.  In- 


a 


deed,    the   movement 
proper  to  the  hip  is  in 

Fig.  30A.— Diagram  to  show  the  Mode  of    ii ,•       «QCO 
Production  of  Lordosis  in  Hip  Disease.     ' 

A,  Femur  flexed  at  hip,  pelvis  (represented  by     to       the 
the    dotted    line)    straight,    and     spine 
normal,      u,   The    flexion     concealed    or 
overcome  l>y  lordosis  of  the  spine ;    the 
pelvis  rendered  oblique. 


spine.  A 
patient  with  a  flexed 
hip  as  the  result  of 
disease  can  lie  on  his 

back  in  bed,  with  both  limbs  apparently  perfectly 
straight,  he  having  concealed  the  flexion,  as  it  were,  by 
producing  a  lordosis  of  the  spine.  If  the  lordosis  be 
corrected,  and  the  spine  be  made  straight  again,  then 
the  flexion  of  the  hip  reappears,  although  all  the  time 
the  hip  joint  has  been  absolutely  rigid.  This  lordosis 
generally  appears  a  little  late  in  the  disease,  and  after 
the  limb  has  become  more  or  less  fixed  in  the  false 
positions  by  contraction  of  the  surrounding  muscles. 


chap,  xix.]  THE  HIP  JOINT.  445 

4.  Sooner  or    later,   in    hip    disease,    the    thigh 
becomes  adducted  and  inverted,  while  it  still  remains 
flexed.     This  position  has  been  variously  accounted 
for.       According     to     one    theory,    it    is     due     to 
softening  and  yielding  of  some  parts  of  the  inflamed 
capsule.     This  view  is  set  forth  by  Mr.  Barker,  in 
his  admirable  monograph  on  joint  disease  in  Holmes' 
"  System     of    Surgery,"    in    the    following    words  : 
"  As  the  inflamed  capsule  commences  to  soften,  its 
weakest  part  yields  first,  i.e.,  the  posterior  inferior 
This  now  admits  of  more  flexion  still.  .  .  .     The  hori- 
zontal posterior  fibres,  which  in  the  distended  condition 
of  the  capsule  help  in  the  eversion,  are  the  next  to 
stretch,  admitting  of  inversion,  which  is  now  the  more 
possible,  as  the  Y  is  relaxed  by  flexion,  and  its  inner 
limb  has  no  strain  to  be  taken  off  by  eversion.     Finally, 
the  upper  and  outer  anterior  fibres  yield,  and  adduction 
then    takes    place."      This    explanation    is   a    little 
unsatisfactory  ;  and  it  is  more  probable  that  this  false 
position,  and  especially  the  adduction,  depends  upon 
muscular  action.    The  muscles  about  the  joint  are  in  a 
state  of  irritability.     They  are  contracted  by  a  reflex 
action  that  starts  from  the  inflamed  articulation,  and 
since  the  adductor  muscles  are  supplied  almost  solely 
by    the  obturator  nerve,   it    is    not  unreasonable  to 
expect    them    to     be     especially    disturbed    if    the 
large  share  that  the   obturator   nerve   takes   in  the 
supply  of  the  hip  be  borne  in  mind.     The  adductors 
are  also  rotators  outwards,  but  this  latter  movement 
would  be  resisted  by  the  strong  outer  limb  of  the  Y 
ligament,  as  well  as  by  the  ligamentum  teres,  both  of 
which  are  rendered  tense  by  rotation  outwards  during 
flexion.     The  whole  matter,  however,  requires  further 
investigation. 

5.  Apparent   shortening  of   the    limb  is   due   to 
tilting   up   of   the   pelvis  on  the  diseased  side,  and 
bears  the  same  relation  to  adduction  that  apparent 


446 


SURGICAL  APPLIED  ANATOMY.     [Chap.  xix. 


lengthening  bears  to  abduction.  To  overcome  the 
adduction,  and  to  restore  the  natural  parallelism  of  the 
limbs,  the  patient  tilts  up  one  side  of  his  pelvis  (Fig. 
39s).  It  thus  happens  that  a  patient  with  his  femur 


Pig.  39B.— A,  Parts  in  Normal  Position.    B,  Femur  acldueted.    c,  The 
Adduction  corrected  by  tilting  up  the  Pelvis. 

uc,  Line  of  pelvis;  ab,  limb  on  diseased  side;  cd,  limb  on  sound  side;  e,  the 
spine.  It  will  be  found  that  ill  Figs.  B  and  c,  the  angle  at  a  is  the  same  in 
the  two  cases. 

flexed  and  adducted  by  disease  may  lie  in  bed  with 
both  limbs  quite  straight  and  parallel,  but  with  one 
limb  obviously  shorter  than  the  other.  The  flexion  in 
such  a  case  is  concealed  by  lordosis,  and  the  adduction 


chap,  xix.]  THE  HIP  JOINT.  447 

by  the  tilting  of  the  pelvis.  In  some  cases  of  simul- 
taneous disease  in  -both  hip  joints  that  has  been  in- 
differently treated,  both  thighs  may  remain  adducted. 
The  limbs  are  unable,  of  course,  to  remedy  their  posi- 
tion by  the  usual  means,  when  the  disease  is  double, 
and  consequently  one  limb  is  crossed  in  front  of  the 
other,  and  the  peculiar  mode  of  progression  known  as 
"  cross-legged  progression  "  is  produced. 

6.  The  real  shortening  depends  upon  destructive 
changes  in  the  head  of  the  bone,  or  to  dislocation  of 
the  partly-disintegrated  head  on  to  the  dorsum  ilii, 
through  yielding  of  the  softened  capsule  and  the 
crumbling  away  of  the  upper  and  posterior  margin  of 
the  acetabulum. 

When  hip  disease  commences  in  bone  it  usually 
involves  the  epiphyseal  line  that  unites  the  head  of 
the  femur  to  the  neck.  This  line  is  wholly  within 
the  joint,  and  the  epiphysis  that  forms  the  head  unites 
with  the  rest  of  the  bone  about  the  eighteenth  or 
nineteenth  year. 

When  the  bone  is  primarily  involved  the  posi- 
tion of  flexion  and  abduction  with  eversion  may 
not  be  observed  at  all,  there  being  no  effusion  at  first 
into  the  joint.  In  such  cases  the  limb  becomes  at 
once  flexed  and  adducted,  and  this  posture  is  probably 
due  solely  to  muscular  spasm,  and  to  an  attempt 
to  prevent  the  head  of  the  femur  from  pressing 
against  the  acetabulum,  and  so  causing  pain. 

It  is  well  known  that  patients  with  hip  disease 
often  complain  of  pain  in  the  knee.  This  referred 
pain  may  be  so  marked  as  to  entirely  withdraw 
attention  from  the  true  seat  of  disease.  Thus  I  once 
had  a  child  sent  to  the  hospital  with  a  sound  knee 
carefully  secured  in  splints,  but  without  any  appli- 
ance to  the  hip,  which  was  the  seat  of  a  somewhat 
active  inflammation.  This  referred  pain  is  easy 
to  understand,  since  the  two  joints  are  supplied 


448  SURGICAL  APPLIED  ANATOMY.     [Chap.  xix. 

by  branches  of  the  same  nerves.  In  the  hip,  branches 
from  the  (1)  anterior  crural  enter  at  the  front  of  the 
capsule  ;  (2)  branches  from  the  obturator  at  the  lower 
and  inner  part  of  the  capsule ;  and  (3)  branches  fi'om 
the  sacral  plexus  and  sciatic  nerve  at  the  posterior 
part  of  the  joint.  In  the  knee,  branches  from  the 
(1)  anterior  crural  (nerves  to  vasti)  enter  at  the  front 
of  the  capsule ;  (2)  branches  from  the  obturator  at 
the  posterior  part  of  the  capsule ;  and  (3)  branches 
from  the  internal  and  external  popliteal  divisions  of 
the  great  sciatic  nerve  at  the  lateral  and  hinder 
aspects  of  the  joint. 

Pain,  therefore,  in  the  front  of  the  knee,  on  ene 
or  both  sides  of  the  patella,  has  probably  been  re- 
ferred along  the  anterior  crural  nerve,  and  pain  at 
the  back  of  the  joint  along  the  obturator  or  sciatic 
nerves. 

In  hysterical  individuals  joint  disease  may  be 
imitated  by  certain  local  nervous  phenomena,  the 
articulation  itself  being  quite  free  from  structural 
change.  This  affection  most  commonly  shows  itself 
in  the  hip  or  knee,  and  the  "  hysterical  hip,"  or 
"hysterical  knee,"  takes  a  prominent  place  in  the 
symptomatology  of  hysteria.  It  is  not  quite  easy  to 
understand  why  these  two  large  joints  should  be  so 
frequently  selected  for  the  mimicry  of  disease.  Hilton 
has  endeavoured  to  explain  the  fact  upon  anatomical 
grounds,  having  reference  to  the  nerve  supply  of  these 
joints  in  relation  to  the  nerve  supply  of  the  uterus. 
The  uterus  is  mainly  supplied  by  an  offshoot  from  the 
hypogastric  plexus,  and  by  the  third  and  fourth  sacral 
nerves.  Now,  the  hypogastric  plexus  contains  fila- 
ments derived  from  the  lower  lumbar  nerves  ;  and  from 
the  same  trunks  two  nerves  to  the  hip  and  knee 
(the  anterior  crural  and  obturator)  are  in  great  part 
derived.  The  great  sciatic  also  contains  a  large 
portion  of  the  third  sacral  nerve.  This  common 


chap,  xix.]     THE  UPPER  END  OF  FEMUR.  449 

origin  of  the  joint  and  the  uterine  nerves  forms  the 
basis  of  Hilton's  explanation  of  the  relative  frequency 
of  hysterical  disease  in  the  large  articulations  of  the 
lower  limb.  The  explanation,  however,  is  unsatisfac- 
tory, since  the  uterus  receives  many  of  its  nerves  from 
the  ovaiian  plexus,  and  the  theory  is  founded  upon 
the  unwarranted  supposition  that  all  hysterical  dis- 
orders are  associated  with  some  affection  of  the 
uterus  or  its  appendages. 

Fractures  of  the  upper  end  of  the  femur 
may  be  divided  into  (1)  fractures  of  the  neck  wholly 
within  the  capsule  ;  (2)  fractures  of  the  base  of  the 
neck  not  wholly  within  the  capsule ;  (3)  fractures  of 
the  base  of  the  neck  involving  the  great  trochanter ; 
(4)  separations  of  epiphyses.  It  must  be  scarcely 
possible,  apart  from  gunshot  injuries,  to  fracture 
the  neck  of  the  femur  by  dii'ect  violence,  owing  to 
the  depth  at  which  the  bone  is  placed,  and  the 
manner  in  which  it  is  protected  by  the  surrounding 
muscles.  The  violence,  therefore,  that  causes  the 
lesion  is  nearly  always  applied  indirectly  to  the  bone, 
as  by  a  fall  upon  the  feet  or  great  trochanter,  or  by  a 
sudden  wrench  of  the  lower  limb. 

M.  Rodet,  by  a  series  of  experiments,  concludes 
that  the  situation  of  the  fracture  can  be  predicated 
by  a  knowledge  of  the  direction  in  which  the  violence 
has  acted.  "  Thus,  a  force  acting  vertically,  as  in 
falling  on  the  feet  or  knees,  will  produce  an  oblique 
intracapsnlar  fracture ;  a  force  acting  from  before 
backwards,  a  transverse  intracapsular  fracture ;  one 
from  behind  forwards,  a  fracture  pai*tly  within  and 
partly  without  the  capsule,  and  a  force  applied 
transversely,  a  fracture  entirely  without  the  capsule." 
(Quoted  by  Henry  Morris ;  Holmes'  "  System  of 
Surgery.") 

1.  The  true  intracapsular  fracture  may  involve 
any  part  of  the  cervix  within  the  joint,  but  is  most 
DD  — 4 


450  SURGICAL  APPLIED  ANATOMY.     [Chap.  xix. 

usually  found  near  the  line  of  junction  of  the  head 
with  the  neck.  This  fracture  is  most  common  in  the 
old,  in  whom  it  may  be  produced  by  very  slight 
degrees  of  violence.  The  liability  of  the  aged 
to  this  lesion  is  explained  upon  the  following 
grounds.  The  angle  between  the  neck  and  shaft 
of  the  femur,  which  will  be  about  130°  in  a 
child,  tends  to  diminish  as  age  advances,  so  that  in 
the  old  it  is  commonly  about  125°.  In  certain  aged 
subjects,  as  a  result  probably  of  gross  degenerative 
changes,  this  angle  may  be  reduced  to  a  right  angle. 
This  diminution  of  the  angle  certainly  increases  the 
risk  of  fracture  of  the  neck  of  the  bone.  There  is 
often  also,  in  advanced  life,  much  fatty  degeneration  of 
the  cancellous  tissue  of  the  cervix  with  thinning  of 
the  compact  layer.  Dr.  Merkel  (Amer.  Journ.  Med. 
Sc.,  1874)  also  asserts  that  in  old  persons  there  is  an 
absorption  of  that  process  of  the  cortical  substance 
which  runs  on  the  anterior  part  of  the  neck  between 
the  lesser  trochanter  and  the  under  part  of  the  head. 
This  process  he  calls  the  "  calcar  femorale,"  and 
maintains  that  it  occupies  the  situation  at  which  the 
greatest  pressure  falls  when  the  body  is  erect.  These 
fractures  are  but  rarely  impacted;  but  when  impacted, 
the  lower  fragment,  represented  by  the  relatively 
small  and  compact  neck,  is  driven  into  the  larger  and 
more  cancellous  fragment  made  up  of  the  head  of  the 
bone.  The  fracture  may  be  subperiosteal,  or  the 
fragments  may  be  held  together  by  the  reflected 
portion  of  the  capsule.  These  reflected  fibres  pass 
along  the  neck  of  the  bone  from  the  attachment  of 
the  capsule  at  the  femur  to  a  point  on  the  cervix 
much  nearer  to  the  head.  "  These  reflected  fibres 
occur  at  three  places,  one  corresponding  in  position  to 
the  middle  of  the  ilio-femoral  ligament,  another  to  the 
pectineo-femoral,  and  the  third  on  the  upper  and  back 
part  of  the  neck  "  (Henry  Morris).  Fractures  of  this 


Chap,  xix.]     THE  UPPER  END  OF  FEMUR.  451 

part  very  rarely  indeed  unite  by  bone.  Blood  is  brought 
to  the  head  of  the  bone  by  the  cervix,  the  reflected 
parts  of  the  capsule,  and  the  ligamentum  teres.  When 
the  first  two  sources  of  blood  supply  are  cut  off  by 
the  fracture  the  third  does  not  appear  to  be  sufficient 
to  allow  of  great  reparative  changes  taking  place 
in  the  upper  fragment.  The  fractures  that  heal  by 
bone  are  probably  either  impacted,  or  subperiosteal, 
or  not  wholly  intracapsular. 

2.  With  regard  to  fractures  at  the  base  of  the 
neck,  it  must  be  remembered  that  a  wholly  extra- 
capsular  fracture  of  the  neck  of  the  femur  is  an 
anatomical  impossibility.  If  the  fracture  is  wholly 
without  the  capsule,  then  it  must  involve  a  part 
of  the  femoral  shaft,  and  cannot  be  entirely  through 
the  cervix.  In  the  front  of  the  bone  the  capsule  is 
attached  to  the  femur  along  a  part  of  the  inter- 
trochanteric  line,  and  strictly  follows  the  line  of 
junction  between  the  cervix  and  the  shaft.  Behind, 
the  capsule  is  inserted  into  the  neck  some  half  of  an 
inch  in  front  of  the  posterior  inter-trochanteric 
line.  It  is  therefore  possible  for  a  fracture  of 
the  neck  to  be  extracapsular  behind,  but  not  in 
fiont,  and  many  of  these  lesions  at  the  base  of  the 
neck  have  this  relation  to  the  capsule.  The  Y  ligament 
is  so  thick,  being  in  one  place  about  a  quarter  of 
an  inch  in  thickness,  that  a  fracture  involving  the 
base  of  the  cervix  may  run  between  its  fibres  at  their 
attachment,  and  be  neither  extra-  nor  intra-capsular. 
When  fractures  at  the  junction  of  the  neck  and  shaft 
ar«  impacted,  the  upper  fragment,  represented  by  the 
compact  and  relatively  small  cervix,  is  driven  into  the 
cancellous  tissue  about  the  great  trochanter  and  upper 
end  of  the  shaft.  As  a  result  of  this  impaction  the 
trochanter  may  be  split  up,  and  the  bones  may 
become  free  again  through  the  extent  of  this 
splintering. 


452  SURGICAL  APPLIED  ANATOMY.    [Chap. xix. 

With  regard  to  the  symptoms  of  a  fracture 
of  the  neck  of  tlic  femur,  the  following  may  be 
noticed  :  (a)  The  swelling  often  observed  in  the  front 
of  the  limb,  just  below  Poupart's  ligament,  is  due 
either  to  effusion  of  blood  into  the  joint,  or  to  pro- 
jection of  the  fragments  against  the  front  of  the 
capsule ;  (b)  the  shortening  is  brought  about  by  the 
glutei,  the  hamstrings,  the  tensor  vagime  femoris,  the 
rectus,  sartorius,  and  ilio-psoas,  the  adductors,  gracilis 
and  pectineus ;  (c)  the  eversion,  or  rotation  out- 
wards of  the  limb,  is  mainly  due  to  two  causes :  (1) 
The  weight  of  the  limb,  which  causes  it  to  roll 
outwards,  as  is  seen  in  persons  insensible  or  asleep, 
4he  line  of  gravity  passing  through  the  outer  part 
of  the  thigh ;  (2)  the  fact  that  the  compact  tissue 
on  the  posterior  aspect  of  the  neck  is  much  more 
fragile  than  that  on  the  -anterior  aspect.  Thus  the 
cervix  is  often  more  extensively  fractured  behind 
than  in  front,  or  the  fracture  may  be  impacted  behind 
but  not  in  front,  and  in  either  case  the  limb  will  tend  to 
become  everted.  As  a  third  cause  may  be  mentioned 
the  action  of  the  ilio  -  psoas,  the  adductor  and 
pectineus  muscles,  and  of  the  small  rotators  muscles, 
all  of  which  will  tend  to  roll  the  femur  outwards. 

3.  Fracture  of   the  base  of   the  neck,  involving 
the  great  trochanter.     In  this  lesion  the  head,   the 
cervix,  and  a  part  of  the  great  trochanter,  are  sepa- 
rated from  the  shaft  and  rest  of  the  trochanter. 

4.  Separation    of    epiphyses.       There    are    three 
epiphyses  in  the  upper  end  of  the  femur,  one  for  the 
head,   which  unites  between  eighteen  and  nineteen  ; 
one   for   the   lesser   troch-xnter,    whicL    unites   about 
seventeen ;  and  one  for  the  greater  trochanter,  which 
unites   about  eighteen.     The  neck  is  formed  by  an 
extension  of  ossification  from  the  shaft.     A  few  cases 
are   recorded   where   it   is   supposed   that  the  caput 
femoris   was    separated   at    the    epiphyseal   line    by 


Chap,  xix.]      DISLOCATIONS  OF  THE  HIP.  453 

violence,  but  the  accident  is,  I  believe,  illustrated  by 
no  actual  specimens.  Mr.  Henry  Morris  has  collected 
five  cases  of  separation  of  the  epiphysis  of  the  great 
trochanter.  This  separation,  if  complete,  could  hardly 
avoid  being  intracapsular  in  part,  since  the  capsule  is 
attached  to  the  anterior  superior  angle  of  the 
trochanter  itself. 

Dislocations  of  the  hip. — These  injuries  are 
comparatively  rare,  on  account  of  the  gredt  strength 
of  the  articulation,  and  when  they  occur  in  a  healthy 
joint  are  always  the  result  of  a  considerable  degree  of 
violence.  A  dislocation  of  the  hip  may  be  congenital, 
or  may  be  spontaneously  produced  by  muscular 
efforts,  as  shown  in  a  few  rare  cases,  or  may  be  the 
result  of  disease  of  the  articulation.  We  are,  how- 
ever, now  concerned  only  with  "regular"  dislocations, 
the  result  of  violence. 

Varieties. — The  head  of  the  bone  may  be  found 
displaced  in  four  directions,  producing  the  four  regular 
dislocations  of  the  hip.  In  two  the  head  of  the  femur 
is  posterior  to  a  line  drawn  vertically  through  the 
acetabulum,  and  in  the  other  two  it  is  found  anterior 
to  that  line. 

(1)  Backwards  and  upwards.  Head  rests  upon 
ilium,  just  above  and  behind  acetabulum.  The  "dis- 
location upon  the  dorsum  ilii."  (2)  Backwards.  Head 
rests  upon  ischium,  and,  as  a  rule,  about  on  a  level 
with  the  ischial  spine.  The  "  dislocation  into  the 
sciatic  notch."  (3)  Forwards  and  downwards.  Head 
rests  on  thyroid  foramen.  The  "  obturator  or  thyroid 
dislocation."  (4)  Forwards  and  upwards.  Head 
rests  upon  the  body  of  the  pubes,  close  to  its  junction 
with  the  ileum.  The  "dislocation  upon  the  pubes." 

The  above  arrangement  represents  also  the  order 
of  frequency  of  these  luxations,  No.  1  being  the  most 
common  dislocation  of  this  part,  and  No.  4  the  most 
rare. 


454  SURGICAL  APPLIED  A tf ATOMY.     iCh»P.  xix 

General  facts. — In  all  these  dislocations  of  the 
hip,  (a)  the  luxation  occurs  when  the  limb  is  in  the 
position  of  abduction ;  (6)  the  rent  in  the  capsule  is 
always  at  its  posterior  and  lower  part ;  (c)  the  head 
of  the  bone  always  passes  at  first  more  or  less  directly 
downwards ;  (d)  the  Y  ligament  is  untorn,  while 
the  ligamentum  teres  is  ruptured. 

(a)  It  is  maintained  that  in  all  luxations  at  the 
hip,  the  pelvis  and  femur  are  in  the  mutual  position 
of  abduction  of  the  latter  at  the  time  of  the  accident. 
The  direction  of  the  neck  of  the  femur  and  of  the 
acetabulum,  and  the  position  of  the  cotyloid  notch,  all 
favour  dislocation  in  the  abducted  posture.  The 
Jower  and  inner  part  of  the  acetabulum  is  very 
shallow,  and  the  lower  and  posterior  part  of  the 
capsule  is  very  thin.  In  abduction,  the  head  of  the 
bone  is  brought  to  the  shallow  part  of  the  acetabulum ; 
it  moves  more  than  half  out  of  that  cavity ;  it  is 
supported  only  by  the  thin  weak  part  of  the  capsule,  and 
its  further  movement  in  the  direction  of  abduction  is 
limited  only  by  the  pectineo- femoral  ligament,  a 
somewhat  feeble  band.  In  abduction  the  round 
ligament  is  slack,  and  in  abduction  with  flexion  both 
the  Y  ligament  and  the  ischio-femoral  ligaments  are 
also  relaxed.  In  the  position  of  abduction,  therefore, 
no  great  degree  of  force  may  be  required  to  thrust  the 
head  of  the  bone  through  the  lower  and  posterior  part 
of  the  capsule,  and  displace  it  downwards. 

(6)  The  above  being  allowed,  it  will  be  understood 
that  the  rent  in  the  capsule  is  always  at  its  posterior 
and  lower  parts.  "  Generally  the  rupture  is  jagged 
and  irregular,  but  will  be  found  to  extend  more  or 
less  directly  from  near  the  shallow  rim  of  the  aceta- 
bulum, across  the  thin  portion  of  the  capsule  to  the 
femur  near  the  small  trochanter,  and  then  to  run 
along  the  back  of  the  ligament  close  to  its  attachment 
to  the  neck  of  the  bone  "  (Henry  Morris). 


cimp.  xix.]     DISLOCATIONS  OF  THE  HIP.  455 

(c)  If  the  position  of  the  limb  at  the  time  of  the 
accident  be  considered,  it  will  be  seen  that  the  femur 
will  in  every  case  be  displaced  downwards.  There  is, 
indeed,  but  one  primary  dislocation  of  the  hip,  a 
luxation  downwards.  The  four  forais  given  above 
are  all  secondary,  the  bone  having  in  each  instance 
first  passed  downwards  before  it  moved  to  any  of 
the  positions  indicated.  This  point  has  been  ably 
demonstrated  by  Mr.  Henry  Morris,  whose  account 
of  the  anatomy  of  hip  dislocations  is  most  valu- 
able. The  head  having  left  the  acetabulum,  its 
ultimate  destination  will  depend  upon  the  character 
of  the  dislocating  foi-ce.  "If  the  limb  be  flexed  on  the 
pelvis,  and  rotated  inwards,  or  the  pelvis  be  corre- 
spondingly moved  on  the  thigh  at  the  moment  of 
displacement,  the  head  of  the  femur  will  take  a 
backward  course,  and  rest  on  the  dorsum  ilii  or  some 
part  of  the  ischium.  On  the  other  hand,  extension 
and  outward  rotation  will  cause  the  head  of  the  bone 
to  travel  upwards  and  forwards,  and  what  is  called  a 

dislocation  on  to  the  pubis  will  occur If  the 

dislocation  is  neither  accompanied  nor  followed  by 
rotation,  or  fixed  flexion  or  extension,  the  head  of  the 
femur  will  remain  below  the  acetabulum,  and  will 
occupy  the  foramen  ovale,  if  it  takes  a  slightly  forward 
direction  in  its  descent,  or  some  position  near  the 
tuberosity  of  the  ischium  if  it  leaves  its  socket  in  a 
backward  and  downward  direction  "  (Henry  Morris). 

(d)  The  Y  ligament  is  never  torn  in  any  "regular" 
dislocation.  It  is  saved  by  its  great  density,  and  the 
circumstance  that  it  is  probably  more  or  less  relaxed 
at  the  time  of  the  luxation.  The  method  of  reducing 
these  dislocations  by  manipulation  depends  for  its 
success  mainly  upon  the  integrity  of  the  Y  ligament, 
which  acts  as  the  fulcrum  to  a  lever  of  which  the 
shaft  of  the  femur  is  the  long  arm,  and  the  neck  the 
short.  In  the  backward  luxations  the  head  is  behind 


456 


SURGICAL  APPLIED  ANATOMY.    [Chap.  xix. 


the  Y  ligament,  and  in  the  forward  displacements  in 
front  of  it. 

The  anatomy  of  each  form. — ^STos.  1  and  2. 

The  dislocations  backwards.  Here  the  femoral  head, 
having  been  displaced  in  the  way  indicated,  is  carried 
towards  the  dorsum  or  sciatic  notch  by  the  glutei, 

hamstring,  and  ad- 
ductor muscles. 
The  bone  having 
taken  a  general 
direction  back- 
wards, the  height  to 
which  it  ascends  de- 
pends mainly  upon 
the  nature  of  the 
dislocating  force, 
and  also  upon  the 
extent  of  the  rup- 
ture in  the  capsule, 
and  the  laceration 
of  the  obturator 
internus  tendon 
and  other  small 
external  rotators. 


Fig.  40.  -Dislocation  npon  the  Dorsuui  ilii 
(Bigelow). 


The  dorsal  disloca- 
tion   is,    therefore, 

a  more  advanced  grade  of  the  sciatic.  The  more 
extreme  the  flexion  and  inward  rotation  at  the  time 
of  the  accident  the  more  likely  is  the  dislocation  to  be 
sciatic.  More  moderate  flexion  and  inward  rotation 
will  produce  a  luxation  upon  the  dorsum.  In  the 
dorsal  luxation  the  head  is  above  the  obturator 
internus  tendon,  while  in  the  sciatic  form  it  is  below 
it  (Bigelow).  Morris  has  been  able  to  find  but  one 
case  of  direct  dislocation  of  the  femur  backwards  on 
to  the  ischium.  In  every  instance  it  passes  first  in  a 
downward  direction,  and  then  backwards. 


Chap,  xix.j     DISLOCATIONS  OF  THE  HIP. 


457 


Bigelow  states  that  there  is  no  evidence  to  show 
that  the  head  of  the  femur  has  ever  been  actually 
displaced  into  the  sciatic  notch. 

In  these  backward  dislocations  the  ilio-psoas 
muscle  is  greatly  stretched.  The  quadratus  femoris, 
the  obturators,  the  gemelli,  and  the  pyriformis  are  more 
or  less  lacerated.  The  pectineus  is  often  torn,  and 
the  glutei  muscles 
even  may  be  ruptured 
in  part.  The  great 
sciatic  nerve  may  be 
compressed  between 
the  femoral  neck  and 
the  rotator  muscles, 
or  between  the  head 
of  the  bone  and  the 
tuber  ischii.  In  both 
of  the  backward  lux- 
ations there  is  shor- 
tening, due  to  the 
circumstance  that  the 
line  between  the  an- 
terior superior  spine 
and  the  femoral 
condyles  is  lessened 

by   the    displacement   F!g  a    -Obturator  or  Thyroid  Disloca- 
backwards     of      the  tion  (Bigelow). 

bone,  with  the  addi- 
tional shortening  in  the  dorsal  dislocation  brought 
about  by  the  passing  of  the  femoral  head  above  the 
level  of  the  acetabulum.  The  adduction  and  in- 
version in  the  main  depend  upon  the  position  of 
the  head  and  cervix,  which  must  follow  the  plane 
of  the  bone  upon  which  they  lie.  This  position 
is  maintained  by  the  tense  Y  ligament.  The 
damage  done  to  the  chief  external  rotators  places 
them  also  hors  de  combat.  The  flexion  is  due  tq 


458 


SURGJCAL  APPLIED  ANATOMY,  [chap.  xix. 


the  tension  of  the  Y  ligament,  and  of  the  ilio-psoas 

muscle. 

Nos.   2  and  3.  The  dislocations  forwards.     If  the 

head  after  leaving  the  acetabulum  simply  moves  a 

little  forwards  along 
the  inner  edge  of  the 
socket,  the  thyroid  lux- 
ation is  produced.  If 
it  goes  farther  and 
moves  upwards,  the 
pubic  displacement  will 
result.  The  latter  dis- 
location is  therefore 
but  an  advanced  form 
of  the  first  -  named. 
Whether  the  head  will 
remain  in  the  thyroid 
foramen  or  ascend  on 
to  the  pubes  depends 
on  whether  extension 
and  rotation  outwards 
accompanies  the  dis- 
placement. If  these 
occur  the  pubic  form 

„.  is  produced.      In  these 

F;g.  42.— Dislocation  upon  the  Pubes      .    .*    . 

(Bigelow).  injuries    the    pectineus, 

gracilis,    and  adductors 

will  be  more  or  less  torn,  while  the  ilio-psoas,  glutei,  and 
pyriform  muscles  are  much  stretched.  The  obturator 
nerve  may  be  stretched  or  torn,  and  in  the  pubic 
luxation  the  anterior  crural  nerve  may  be  involved. 
The  abduction  and  eversion  of  the  limb  noticed  in 
these  luxations  depend  partly  upon  the  position  of 
the  head  of  the  bone,  fixed  more  or  less  by  the 
Y  ligament,  and  partly  upon  the  action  of  the  gluteai 
muscles  and  some  of  the  small  external  rotators, 
which  are  tightly  stretched,  The  flexion  of  the 


Chap,  xix.]     DISLOCATIONS  OF  THE  HIP.  459 

limb  is   mainly  due  to   the   stretching   of   the   ilio- 
psoas  muscle. 

In  the  thyroid  luxation  the  extremity  is  said  to  be 
lengthened.  This  lengthening  is,  however,  apparent, 
and  is  due  to  the  tilting  down  of  the  pelvis  on  the 
injured  side.  In  the  pubic  dislocation  there  is 
shortening,  the  head  being  carried  above  the  ace 
tabular  level. 

.  Of  the  modes  of  reducing  these  dislocations  by 
manipulation  little  can  be  said  here.  The  more 
usual  proceedings  may  be  briefly  summarised  as 
follows  : 

First. — Flex  the  thigh  in  the  adducted 
position  in  luxations  Nos.  1 


and  2. 
Flex  the  thigh  in  the  abducted 


To  relax  the 
Y  ligament. 


position  in  luxations  Nos.  3 
and  4. 

Secondly. — Circumduct  out  in^  To  bring  back  the  head 

Nos.  1  and  2.     (to  the  rent  in  the  cap- 

Circumduct  in  in  f  sule  by  the  same  route 

Nos.  3  and  4.    )  that  it  has  escaped. 
Thirdly. — Extend  in  all  cases.      To  induce  the  head 

to  again  enter  the  acetabulum. 
In  reducing  dislocations  of  the  hip  it  may  be  noted 
that  the  internal  condyle  of  the  femur  faces  in  nearly 
the  same  direction  as  the  head  of  the  bone. 

In  amputation  at  the  hip-joint  by  long 
anterior  and  short  posterior  flaps  the  following  parts 
are  divided.  In  the  face  of  the  anterior  flap  will  be 
seen  sections  of  the  tensor  vaginae  femoris,  rectus,  part 
of  the  vasti,  the  adductors  longus  and  brevis,  and  the 
gracilis.  Close  to  the  acetabulum  in  front  are  sections 
of  the  ilio-psoas  and  pectineus  muscles,  and  behind 
and  to  the  inner  side  the  obturator  extemus.  In 
this  flap  also,  close  to  the  angle  between  it  and  the 
posterior  flap,  are  small  portions  of  the  slutei  to  the 


460 


Si'RGICAL    AlT LIED   ANATOMY.    [Chap.  XIX. 


outer  side  of  the  hip,  and  of  the  adductor  magnus  to 
the  inner  side.  The  cut  end  of  the  sartorius  is  found 
on  the  lower  edge  of  the  flap.  The  femoral  and 


Fig.  43.— Amputation  at  Hip  Joint  (Agntz). 

a,  Head  of  femur:  b,  acetabulum ;  r,  part  of  eapsular  ligament:  rf,  adductor 
lonjrus;  e,  adductor  magnus:  /,  pectineus;  <7,  rectus ;  A,  tensor  vaerina? 
femoris  ;  /,  ilio-psoas  ;  j,  sartorius ;  A',  femoral  and  profuuda  vessels ;  /,  irri -iit 
saphenous  vein  ;  m,  anterior  crural  nerve. 

profunda  vessels,  together  with  the  saphenous  vein 
and  the  anterior  crural  and  superficial  nerves,  are  cut 
in  the  lower  edge  of  the  flap.  On  the  face  of  the  flap 
are  branches  of  the  profunda  and  external  circumflex 
vessels,  while  the  trunk  of  the  internal  circumflex 
artery  is  cut  close  to  the  acetabulum  on  its  inner  side. 
The  face  of  the  posterior  flap  exposes  the  glutei 
muscles,  hamstrings,  and  adductor  magnus.  Deeper 
in  the  flap  are  divided  the  small  external  rotators. 


Chap,  xx.]  THE  THIGH.  461 

Amputation  of  the  hip  is  usually  now  performed  by 
means  of  some  form  of  racket  incision.  (See  the  author's 
"  Operative  Surgery.")  The  sciatic  nerves  and  vessels 
are  cut  on  the  lower  border  of  the  flap,  while  on  its 
face  are  divided  branches  of  the  sciatic,  perforating, 
and  circumflex  arteries. 


CHAPTER  XX. 

THE   THIGH. 

UNDER  the  term  "  the  thigh  "  it  will  be  convenient 
to  describe  that  part  of  the  lower  limb  that  extends 
between  the  regions  just  described,  and  the  districts 
of  the  knee  and  popliteal  space. 

Surface  anatomy. — In  muscular  subjects  the 
outline  of  the  thigh  is  irregular,  but  in  the  less 
muscularly  developed,  who  are  provided  with  a  good 
share  of  subcutaneous  fat,  the  limb,  in  this  section  of 
it,  is  more  or  less  evenly  rounded.  The  prominence 
of  the  rectus  muscle  is  noticeable  on  the  front  of  the 
thigh,  especially  when  the  muscle  is  in  action.  To 
the  inner  side  of  this  structure,  and  conspicuous  along 
the  lower  half  of  the  thigh,  is  the  eminence  formed 
by  the  vastus  internus.  The  mass  to  the  outer  side 
of  the  rectus  is  composed  of  the  external  vastus 
muscle,  and  occupies  the  greater  part  of  the  limb  in 
this  region,  being,  however,  more  conspicuous  below. 

Eunning  down  the  anterior  and  inner  aspect  of 
the  thigh,  from  the  apex  of  Scarpa's  triangle,  is  a 
depression  which  indicates  the  interval  between  the 
quadriceps  muscle  and  the  adductors.  Along  this 
groove  the  sartorius  lies.  Over  the  surface  of  the 
vastus  externus  a  longitudinal  depression  is  often  to 
be  observed  formed  by  the  pressure  exercised  by  the 
superimposed  ilio-tibial  band  of  the  fascia  lata  (Quain'a 


462  SURGICAL  APPLIED  ANATOMY.     [Chap. xx, 

"Anatomy").  The  hamstring  muscles  cannot  usually 
be  distinguished  the  one  from  the  other  above  the 
popliteal  space,  nor  is  their  separation  from  the  ad 
ductors  indicated.  The  separation,  however,  between 
them  and  the  vastus  externus  is  distinct,  and  corre- 
sponds to  the  position  of  the  external  inter-muscular 
septum.  The  line  of  the  femoral  vessels  has  already 
been  given.  The  long  saphenous  vein  follows  in  the 
thigh  the  course  of  the  sartorius  muscle,  and  may  be 
represented  on  the  surface  by  a  line  drawn  from  the 
region  of  the  saphenous  opening  (page  434)  to  the 
posterior  border  of  the  sartorius  muscle  at  the  level 
of  the  inner  condyle  of  the  femur.  The  long  saphenous 
-jierve  follows  the  course  of  the  femoral  artery,  lying 
first  to  the  outer  side  of  that  vessel,  and  then  gradually 
crossing  it.  Tn  the  lower  fourth  of  the  thigh  the 
nerve  passes  under  cover  of  the  sartorius  muscle  to 
the  inner  side  of  the  knee,  and  is  accompanied  by  the 
superficial  branch  of  the  anastomotic  artery.  A  line 
drawn  down  the  back  of  the  limb  from  a  point  midway 
between  the  great  trochanter  and  tuber  ischii  to  the 
middle  of  the  ham  will  correspond  to  the  great 
sciatic  nerve  and  one  of  its  continuations,  the  internal 
popliteal.  The  great  trunk  usually  bifurcates  a  little 
below  the  middle  of  the  thigh. 

The  skin  of  the  thigh  is  coarse  on  the  outer  side 
of  the  limb,  but  internally  it  is  thin  and  fine,  and  is 
apt  to  be  readily  excoriated  by  ill-applied  bandages  or 
splints.  It  is  but  loosely  attached  to  the  subjacent 
parts,  a  circumstance  that  greatly  favours  the 
performance  of  circular  amputations  in  this  region. 
At  one  place,  however,  it  is  a  little  more  adherent, 
viz.,  along  the  groove  that  separates  the  vastus 
externus  behind  from  the  hamstring  muscles,  and  that 
corresponds  to  the  outer  intermuscular  septum.  The 
laxity  of  the  subcutaneous  tissue  favours  extensive 
extravasations  beneath  the  skin,  and  permits  of  large 


chap,  xx.)  THE  THIGH.  463 

flaps  of  integunuent  being  torn  up  in  cases  of  injury  to 
this  part  of  the  extremity. 

The  fascia  lata  invests  the  limb  at  all  parts  like 
a  tightly-fitting  sleeve.  It  is  thickest  at  its  outer 
side,  where  it  forms  the  dense  ilio-tibial  band.  It  is 
thinnest  at  the  upper  and  inner  aspect  of  the  thigh, 
where  it  covers  the  adductor  muscles.  It  increases 
considerably  in  strength  as  it  approaches  the  front  of 
the  knee,  and  attaches  itself  to  the  tibia  and  lateral 
margins  of  the  patella.  This  fascia  resists,  especially 
at  its  outer  part,  the  growth  of  tumours  and  abscesses, 
and  limits  deep  extravasations  of  blood.  It  has 
occasionally  been  ruptured  in  part  by  violence,  and 
through  the  rent  so  formed  the  subjacent  muscle 
has  bulged,  forming  what  is  known  as  a  hernia  of 
the  muscla  This  condition  has  been  met  with  in  the 
case  of  the  quadriceps  muscle,  and  also  of  the  adductor 
longus.  Such  "  hernise  "  are  probably  associated  with 
some  rupture  of  the  fibres  of  the  muscles  implicated. 
Two  deep  processes  of  the  fascia  are  attached  to  the 
femur,  and  form  the  outer  and  inner  intermuscular 
septa.  The  outer  septum  separates  the  vastus 
externus  from  the  biceps,  and  the  inner  the  vastus 
internus  from  the  adductors.  Together  with  the 
fascia  lata,  these  septa  divide  the  thigh  into  two 
appneurotic  spaces,  which  can  be  displayed  in  a 
transverse  section  of  the  limb.  These  divisions, 
however,  are  of  little  surgical  moment,  and  the  inner 
septum  is  often  so  thin  and  feeble  that  it  could  have 
little  effect  in  directing  the  course  of  an  abscess. 

In  circular  amputations  of  the  thigh  the  muscles 
are  apt  to  retract  a  little  unevenly,  since  some  are 
attached  to  the  femoral  shaft  while  others  are  free. 
The  muscles  so  attached  are  the  adductors,  vasti  and 
crureus,  while  the  free  muscles  are  the  sartorius,  rectus, 
hamstrings,  and  gracilis. 

In  spite  of  its  great  strength  the  tendon  of  the 


464  SURGICAL  APPLIED  AN  ATOM?,    [ciup.  xx. 

quadriceps  may  be  ruptured  by  muscular  violence.  A 
good  example  of  such  an  accident  is  recorded  by  Mr. 
Bryant  (Mecl.  Times,  1878).  A  man  aged  forty-two 
stumbled  in  the  dark,  and  fell  down  a  pit  ten  feet 
deep.  On  examination  the  tendon  was  found  to  be 
torn  across,  and  the  gap  above  the  patella  produced  by 
the  rupture  occupied  no  less  extent  than  the  lower  third 
of  the  thigh.  A  somewhat  more  remarkable  accident 
is  reported  to  have  happened  to  the  sartorius  muscle. 
This  muscle,  just  before  its  insertion  into  the  tibia, 
gives  off  an  aponeurotic  expansion  from  its  anterior 
border  to  the  capsule  of  the  knee-joint.  In  the  case 
alluded  to  (Lancet,  1873),  this  expansion  is  said  to 
«have  been  ruptured,  and  the  muscle  itself  to  have  been 
found  dislocated  backwards  in  consequence.  The 
accident  befell  a  man  aged  forty,  who  was  squatting, 
in  the  position  assumed  by  tailors,  upon  the  floor  of  a 
wagon,  when  his  companion  tripped  over  him,  and 
fell  across  his  bent  knees.  Something  was  felt  to 
have  given  way  near  the  ham,  and  on  examination  the 
above  lesion  was  diagnosed. 

The  femoral  artery  may  be  ligatured  at  any  part 
of  its  course  in  the  thigh,  and  the  comparatively  super- 
ficial position  of  the  vessel  renders  it  very  liable  to  be 
injured.  The  thigh  affords  many  instances  of  the 
remarkable  way  in  which  isolated  branches  of  a  main 
artery  are  often  alone  damaged.  Thus,  Langier  relates 
the  case  of  a  man-cook,  who,  in  running  round  a  table, 
struck  the  upper  and  outer  side  of  his  thigh  against 
the  corner  of  it.  This  led  to  a  subcutaneous  rupture 
of  the  external  circumflex  artery.  Unfortunately  the 
extravasation  was  cut  into,  and  the  patient,  after 
being  subjected  to  many  modes  of  treatment,  died 
from  the  effects  of  repeated  haemorrhage.  Dr.  Butcher 
(Dub.  Joum.  Med.  Sc.,  1874),  gives  the  case  of  a  man 
who  was  stabbed  in  the  thigh  over  the  femoral  vessels 
during  a  scuffle.  Profuse  bleeding  followed,  and  it  was 


chap,  xx.]  THE  THIGH.  465 

found  that  the  only  vessel  woimded  was  the  internal 
circumflex  artery,  just  at  its  point  of  origin  from  the 
profunda.  The  case  was  treated  promptly  and  the 
man  did  well. 

Fractures  of  the  femur. — The  shaft  of  the 
femur  may  be  broken  at  any  part,  but  the  lesion  is 
most  common  at  the  middle  third  of  the  bone,  and 
least  frequent  at  its  upper  third.  If  broken  by  direct 
violence  the  fracture  is  usually  transverse,  and  if  by 
indirec.t  violence  it  is  usually  oblique.  The  probability 
of  a  fracture  being  due  to  direct  violence  diminishes 
in  the  bone  from  below  upwards,  while  the  probability 
of  a  lesion  from  indirect  violence  increases  in  the 
same  direction.  Thus  it  happens  that  the  fractures 
of  the  upper  third  of  the  bone  are  usually  oblique, 
while  those  of  the  lower  third  are  more  commonly 
transverse.  In  the  middle  third  the  numbers  of  the 
transverse  and  oblique  fractures  are  more  nearly 
balanced.  The  femur  has  often  been  broken  by 
muscular  violence,  but  it  is  doubtful  if  this  has  ever 
occurred  in  other  than  a  diseased  bone.  In  many  of 
these  cases  the  amount  of  force  that  breaks  the  bone 
is  most  insignificant.  Thus  Vallin  reports  the  case  of 
a  girl  aged  eighteen,  described  as  robust,  who  broke 
the  femur  about  its  middle  while  in  the  act  of 
mounting  a  table  for  the  purpose  of  undergoing  a 
vaginal  examination.  In  oblique  fractures  in  the 
upper  third  of  the  bone  the  line  of  fracture  usually  runs 
downwai-ds  and  inwards,  while  in  oblique  fractures  of 
the  middle  third  the  direction  is  more  commonly 
downwards  and  forwards,  with  a  slight  lateral  inclina- 
tion that  is  sometimes  inwards  and  sometimes  out- 
wards. Fractures  of  the  lower  third  of  the  bone  are 
discussed  in  connection  with  the  region  of  the  knee 
(chap.  xxi.). 

With  regard  to  fractures  of  the  upper  and  middle 
thirds,  the  displacement  of  the  fragments  depends 
BE — 4 


466  SURGICAL  APPLIED  A  ff ATOMY.    [Chap. xx. 

greatly  upon  the  obliquity  of  the  fracture.  As  a  rule 
the  lower  fragment  is  drawn  up  behind  the  upper 
one  by  the  hamstrings,  aided  by  the  rectus,  gra- 
cilis,  sartorius,  tensor  vaginae,  and  adductors,  and  is 
carried  a  little  to  its  inner  side  under  the  influence 
of  the  last-named  muscles.  The  lower  end  of  the 
upper  fragment  usually  projects  forwards  and  a  little 
outwards.  This  is  produced  by  the  agency  of  the 
lower  fragment,  which  tilts  the  upper  piece  of  bone  in 
the  direction  named.  In  the  fracture  of  the  upper 
third  of  the  shaft  the  projection  forwards  of  the  upper 
fragment  is  aided  by  the  ilio-psoas  muscle.  Thus  the 
deformity  produced  in  fractures  of  the  femoral  shaft 
is  usually  angular  in  character.  The  eversion  of  the 
foot  noted  in  fractures  of  the  femur  is  due  to  the 
weight  of  the  limb,  which  causes  the  helpless  member 
to  roll  out,  aided  probably  by  the  action  of  the 
external  rotator  muscles. 

Certain  spiral  fractures  (helicoidul  fractures  of 
Leriche)  may  be  produced  in  the  lower  part  of  the 
shaft  as  the  result  of  torsion.  M.  Fere  finds  by 
experiment  that  if  the  limb  be  carried  forwards  in 
front  of  the  opposite  knee,  and  the  foot  rotated 
outwards,  a  spiral  fracture  can  be  produced  at  the 
junction  of  the  lower  and  middle  thirds  of  the  femur. 
A  like  fracture  at  the  same  level,  but  with  the 
direction  of  the  spiral  reversed,  can  be  produced  by 
carrying  the  limb  outwards  and  then  rotating  it 
inwards. 

Shortening  of  the  limb  after  fracture. — 
It  is  doubtful  if  a  fracture  of  the  shaft  of  the  femur 
can,  after  any  treatment,  become  united  without  some 
shortening  resulting,  except  in  a  few  exceptional  cases. 
It  is  important,  in  connection  with  this  subject,  to 
remember  that  the  lower  limbs  may  be  normally  of 
unequal  length.  Dr.  Wight,  of  Brooklyn,  has  fully 
investigated  this  matter,  and  has  arrived  at  the 


Chap.  XX  J 


THE  THIGH. 


467 


following  conclusions :  (1)  The  greater  number  of 
normal  lower  limbs  are  of  unequal  length  ;  (2)  the 
left  limb  is  oftener  longer  than  the  right;  (3)  the 
average  inequality  of  normal  lower  limbs  is  probably 


Fig.  44.— Transverse  Section  through  the  Middle  of  the  Thigh 
(Brauue). 


cutaneous  nerVe  ;~5)  external  cutaneous' nerve  ;  6,  perforating  branches  from 
profunda :  7.  small  scintic  nerve. 

about  a  quarter  of  an  inch ;  (4)  the  average  amount  of 
shortening  after  a  fracture  of  the  femur  that  has  been 
well  treated  is  about  three-quarters  of  an  inch  ;  (5)  in 
about  one  case  in  ten  or  eleven  the  two  limbs  will  be 
found  to  be  of  equal  length  after  the  union  of  the 
fracture;  (6)  one  limb  can  never  be  a  certain  standard 
of  length  for  the  opposite  limb.  Dr.  Garson,  as  a 
result  of  the  careful  examination  of  some  seventy 
skeletons,  states  that  both  the  lower  limbs  are  of 
equal  length  in  only  about  ten  per  cent,  of  all  cases. 


468  SURGICAL  APPLIED  ANATOMY.    [Chap.  xxi. 

He  also  found   that  the  femur  was  more  frequently 
the  seat  of  variation  than  the  tibia. 

Amputation  of  the  thigh. — In  a  circular 
amputation  of  the  thigh  about  its  middle  the  following 
parts  would  be  divided :  the  quadriceps,  sartorius, 
gracilis,  long  and  great  adductors,  and  the  three 
hamstring  muscles  ;  the  femoral  and  profunda  vessels, 
the  descending  branches  of  the  external  circumflex 
artery,  the  lower  perforating  vessels,  and  the  long 
saphenous  vein ;  the  main  branches  of  the  anterior 
crural  nerve  (middle  cutaneous,  internal  cutaneous, 
and  muscular,  together  with  the  long  saphenous 
nerve),  the  anterior  branch  of  the  external  cutaneous 
.nerve,  the  obturator,  and  the  great  and  small  sciatic 
nerves.  Owing  to  the  unequal  manner  in  which  the 
divided  muscles  retract,  a  circular  amputation  is  not 
well  adapted  for  the  thigh. 


CHAPTER  XXI. 

THE    REGION   OP   THE    KNEE. 

IN  this  chapter  will  be  considered  the  articulation 
of  the  knee,  the  soft  parts  about  the  joint,  the 
popliteal  space,  the  lower  end  of  the  femur,  the 
patella,  and  the  upper  ends  of  the  tibia  and  fibula. 

Surface  anatomy. — In  the  front  of  the  knee 
the  patella  can  be  distinctly  felt  and  seen.  Its  inner 
border  is  a  little  more  prominent  than  the  outer. 
When  the  limb  lies  in  the  extended  posture,  with  the 
quadriceps  relaxed,  the  patella  can  be  moved  to  and 
fro,  and  appears  to  be  but  loosely  attached.  When 
the  quadriceps  is  contracted  the  bone  is  drawn 
upwards,  and  becomes  firmly  fixed  against  the  femur. 
In  flexion  of  the  joint  the  patella  sinks  into  the 


fcW.  xxi.]     THE  REGION  OF  THE  £NEE.  469 

hollow  between  the  tibia  and  the  intercondyloid  notch, 
and  is  very  firmly  fixed.  In  this  position  some  part 
of  the  trochlear  surface  of  the  femur  can  be  made  out 
above  the  patella.  On  each  side  of  the  knee-cap  a 
hollow  exists  which  may  be  completely  filled  up  with 
fat  in  the  obese. 

When  the  limb  lies  in  the  extended  posture  the 
ligamentum  patellae  is  not  to  be  very  distinctly  made 
out.  It  becomes  a  little  more  conspicuous  in  the 
flexed  position,  and  is  most  prominent  when  the 
quadriceps  muscle  is  vigorously  contracted. 

On  the  inner  side  of  the  knee  the  following  parts 
can  be  felt  from  above  downwards :  the  tubercle  for 
the  adductor  magnus,  and  the  tendon  of  insertion  of 
that  muscle  ;  the  inner  condyle  of  the  femur,  which 
is  very  prominent,  and  forms  the  chief  part  of  the 
rounded  eminence  on  this  aspect  of  the  joint ;  and 
below  this  the  inner  tuberosity  of  the  tibia.  Between 
the  two  latter  processes  of  bone  the  interarticular 
line  is  easily  to  be  felt.  On  the  outer  side  of  the 
joint  is  the  external  condyle  of  the  femur,  which  is 
much  less  conspicuous  than  its  fellow  of  the  opposite 
side,  and  below  it  is  the  corresponding  tuberosity  of 
the  tibia,  forming  a  marked  prominence.  Immediately 
in  front  of  the  biceps  tendon  the  upper  part  of  the 
external  lateral  ligament  can  be  felt  when  the  joint  is 
a  little  flexed.  Between  the  tendon  and  the  patella, 
the  lower  part  of  the  ilio-tibial  process  of  the  fascia 
lata  can  be  detected  as  a  prominent  rounded  band, 
descending  to  the  external  tuberosity  of  the  tibia.  It  is 
most  distinct  when  the  knee-joint  is  forcibly  extended 
by  muscular  action,  and  often  stands  out  conspicuously 
beneath  the  skin.  The  tubercle  of  the  tibia  and  the 
head  of  the  fibula  are  both  to  be  readily  felt,  and  are 
nearly  on  the  same  level. 

The  popliteal  space  only  appears  as  a  hollow  when 
the  knee  is  bent.  In  the  extended  limb  the  hollow  is 


SURGICAL  APPLIED  ANATOMY.  [Chap.  xxi. 

replaced  by  an  evenly  rounded  eminence.  The  crease 
in  the  skin  that  passes  transversely  across  the  ham  ia 
some  way  above  the  line  of  the  knee-joint.  On  the 
outer  side  of  the  space  the  biceps  tendon  can  be  very 
readily  felt,  especially  when  the  muscle  is  in  action. 
Just  behind  it,  and  along  its  inner  border,  lies  the 
peroneal  nerve.  It  can  be  rolled  under  the  finger  as 
it  crosses  the  head  of  the  fibula  to  pass  beneath  the 
peroiieus  longus  muscle.  On  the  inner  side  of  the 
ham  three  tendons  can  be  felt.  Nearest  to  the  middle 
of  the  space  is  the  long  prominent  tendon  of  the 
semitendinosus.  Internally  to  it  is  the  larger  and 
less  distinct  semimembranosus  tendon,  and  still  more 
to  the  inner  side  the  gracilis  may  be  made  out. 

The  popliteal  vessels  enter  the  ham  obliquely  at 
its  upper  and  inner  part,  and  under  cover  of  the 
semimembranosus  muscle.  The  outer  border  of  this 
muscle  is  the  guide  to  the  upper  portion  of  the  artery. 
The  vessels  in  their  descent  reach  a  point  behind 
the  middle  of  the  knee-joint,  and  then  pass  vertically 
downwards.  The  termination  of  the  popliteal  artery 
is  on  a  level  with  the  lower  part  of  the  tubercle  of 
the  tibia.  When  the  limb  is  flexed,  the  pulsations  of  the 
artery  can  be  felt  and  the  vessel  compressed  against  the 
femur  a  little  below  its  point  of  entry  into  the  popliteal 
space.  The  upper  articular  arteries  run  transversely 
inwards  and  outwards  just  above  the  femoral  condyles. 
The  lower  articular  arteries  are  also  placed  trans- 
versely, the  inner  vessels  running  just  below  the 
internal  tuberosity  of  the  tibia,  and  the  outer  just 
above  the  head  of  the  fibula.  The  deep  branch  of 
the  anastomctica  magna  descends  to  the  inner  condyle 
of  the  femur  in  the  substance  of  the  vastus  in  tern  us, 
and  along  the  front  of  the  adductor  magnus  tendon. 
The  internal  saphenous  vein  passes  up  along  the  back 
part  of  the  internal  condyle  of  the  femur,  and  then 
follows  the  sartorius  muscle  to  the  thigh.  It  is  just 


Chap,  xxi.]      THE  REGION  OF  THE  KNEE.  47 1 

below  the  interarticular  line  that  the  long  saphenous 
nerve  usually  joins  the  vein.  The  short  saphenous 
vein  follows  the  middle  line  of  the  calf  just  below 
the  ham,  and  pierces  the  deep  fascia  at  the  lower  part 
of  the  popliteal  space.  This  vessel  is  much  less  con- 
spicuous than  is  the  long  saphenous  vein,  and  is, 
indeed,  not  often  to  be  seen  unless  varicose. 

The  internal  popliteal  nerve  descends  in  the 
middle  line,  and  continues  the  line  that  marks  the 
course  of  the  great  sciatic  trunk. 

In  their  normal  condition  the  popliteal  glands  are 
not  to  be  felt. 

The  limits  of  the  synovial  membrane  of  the  knee- 
joint,  and  the  position  of  the  various  bursse  about 
this  articulation,  will  be  dealt  with  in  some  of  the 
subsequent  paragraphs. 

The  front  of  the  knee. — The  skin  over,  the 
front  of  the  knee  is  dense  and  very  movable.  This 
mobility  affords  considerable  protection  to  the  knee- 
joint,  especially  in  stabs  with  bluntish  instruments, 
and  in  any  injury  where  the  gliding  movement  of  the 
skin  may  direct  the  violence  away  from  the  articula- 
tion. The  comparative  looseness  of  the  integument 
is  of  great  value  also  in  the  operation  of  removing 
so-called  "  loose  cartilages"  from  the  knee-joint.  It 
permits  the  incision  into  the  joint  to  be  very  indirect, 
and,  the  skin  being  dragged  out  of  place  during  the 
operation,  it  follows  that,  when  the  procedure  is  com- 
plete, the  surface  wound  and  that  in  the  knee  capsule 
no  longer  correspond.  In  flexion,  the  skin  is  drawn 
tightly  over  the  patella,  and,  as  is  the  case  elsewhere, 
where  integument  lies  more  or  less  directly  upon  bone, 
a  contusion  over  the  knee-cap  may  produce  a  lesion 
precisely  like  an  incised  wound. 

In  the  Lancet  for  1877  is  recorded  the  case  of  a 
very  stout  woman,  aged  fifty-seven,  who,  stumbling 
on  a  hard  road,  fell  upon  her  bent  knee.  The  skin 


472  SURGICAL  APPLIED  ANATOMY.  [Chap,  xxi, 

was  burst  across  the  front  of  the  knee,  and  a  wound 
was  produced  that  was  seven  inches  in  length,  and 
was  as  cleanly  cut  as  if  made  by  a  scalpel. 

There  is  but  little  subcutaneous  fat  in  front  of 
the  articulation,  and  thus  it  happens  that  in  amputa- 
tions through  the  knee-joint  the  anterior  flap  is  very 
thin,  and  is  composed  of  little  other  than  the  simple 
integument. 

As  blisters,  and  various  forms  of  counter-irri- 
tant, are  often  applied  to  the  front  of  the  knee  in 
cases  of  disease,  it  may  be  well  to  take  note  of  the 
blood-supply  of  this  part,  and  of  the  relations  between 
the  surface  vessels  and  those  of  the  joint.  The 
vessels  that  give  branches  to  the  front  of  the  knee, 
and  that  are  concerned  in  the  supply  of  the  part  to 
which  blisters  are  usually  applied,  are  the  anastomotic, 
the  four  articular  branches  of  the  popliteal,  and  the 
anterior  tibial  recurrent.  Now  of  these  arteries,  and 
especially  of  the  anastomotica  magna  and  superior 
articular,  it  may  be  said  that,  shortly  after  their 
origin,  they  divide  into  two  branches,  or  two  sets  of 
branches,  one  going  to  the  surface  and  the  other  to 
the  articulation  of  the  knee  and  deeper  parts  about 
it.  It  may  be  supposed,  therefore,  tliat,  in  applying 
a  counter-irritant  in  front  of  the  knee  for  the  relief 
of  a  joint  affection,  a  greatly  increased  quantity  of 
blood  is  drawn  into  the  superficial  divisions  of  the 
above-named  vessels,  and  less  blood  is  thereby  left- 
to  flow  by  their  deeper  branches  to  the  seat  of 
disease. 

The  superficial  lymphatics  in  the  region  of  the 
knee  lie  for  the  most  part  on  the  inner  aspect  of  the 
joint,  and  follow  the  course  of  the  long  saphenoua 
vein.  Ulcers,  and  other  inflammatory  affections  of 
the  skin  over  the  articulation,  are  more  apt  to  be 
associated  with  lymphangitis  and  with  enlargement  of 
the  inguinal  glands  when  situate  on  the  inner  aspect 


ch«p.  xxi.j         THE  POPLITEAL  SPACE.  473 

of  the  joint  than  when  placed  in  front  or  to  the  outer 
side  of  it. 

The  bursae  over  the  front  of  the  knee. — (1)  The 
patellar  bursa  is  a  large  sac  placed  in  front  of  the 
patella  and  upper  part  of  the  patellar  ligament,  and 
separates  those  structures  from  the  skin.  It  is  very 
often  found  enlarged  in  those  who  kneel  much,  in 
housemaids,  stone-masons,  religieuses,  etc.  The  parts 
about  are  well  supplied  with  nerves,  and  hence  much 
pain  is  usually  associated  with  acute  inflammation  of 
this  sac.  It  is  in  close  contact  with  the  patella,  and, 
in  one  case  reported  by  Erichsen,  suppuration  of  the 
bursa  led  to  caries  of  that  bone  (Figs.  45,  46,  and 
49).  (2)  There  is  a  small  bursa  between  the 
patellar  ligament  and  the  tubercle  of  the  tibia 
( Fig.  46).  When  inflamed,  it  causes  more  pain 
than  is  observed  in  affections  of  the  previous  bursa, 
since  it  is  firmly  compressed  between  two  rigid  struc- 
tures, the  ligament  and  the  bone.  It  is  separated 
from  the  synovial  cavity  by  the  pad  of  fat  that  lies 
behind  the  patella.  It  would  appear,  however,  to 
sometimes  communicate  with  the  joint,  since  Hamilton 
has  collected  three  cases  where  incision  into  this 
bursa  led  to  suppuration  of  the  articulation.  There 
is  a  pad  of  soft  fat  between  the  ligament  and  the 
tibial  tubercle,  which  often  protrudes  a  little  at  either 
side  of  the  former  structure,  and  has  been  mistaken 
for  an  enlarged  bursa.  (3)  The  bursa  between  the 
quadriceps  tendon  and  the  femur  will  be  considered 
in  connection  with  the  synovial  cavity. 

The  popliteal  space.  —  The  skin  over  the 
space  is  not  so  movable  as  is  that  over  the  front  of 
the  knee.  When  destroyed  by  injury,  by  burns,  or 
by  extensive  ulceration,  the  contraction  of  the  result- 
ing cicatrix  may  lead  to  a  rigidly-bent  knee.  The 
skin  in  this  place  has  also  been  ruptured  by  forcible 
extension  applied  to  the  limb  in  cases  of  contracted 


474  SURGICAL  APPLIED  ANATOMY,  rchap.  xxi. 

knee.  Beneath  the  skin  and  superficial  tissue  is  the 
popliteal  fascia,  a  dense  membrane  that  covers  in  the 
space.  It  is  but  a  continuation  of  the  fascia  lata  of 
the  thigh,  and  is  continuous  below  with  the  fascia  of 
the  leg.  It  passes  without  bony  attachment  over  the 
hamstring  muscles  that  bound  the  ham.  This  fascia 
limits,  often  in  a  very  marked  manner,  the  progress  of 
popliteal  abscesses  and  growths  towards  the  surface. 
Its  unyielding  character  is  a  prime  cause  in  the  pro- 
duction of  the  severe  pain  with  which  such  collections 
and  tumours  are  often  associated.  The  popliteal 
abscess,  unable  to  reach  the  surface,  is  encouraged  to 
extend  either  up  into  the  thigh  or  down  the  leg.  The 
>ham  may  hold  a  very  considerable  quantity  of  pus. 
Velpeau  has  seen  a  case  where  a  litre  (1  pint,  15  ozs.) 
of  pus  was  evacuated  from  this  region  in  a  patient 
who  presented  before  the  operation  but  an  insignificant 
swelling  in  the  site  of  the  collection.  Duplay  records 
two  cases  of  ulceration  of  an  abscess  into  the  popli- 
teal artery,  and  Ollivier  an  instance  where  the  abscess, 
unable  to  find  a  way  to  escape,  ultimately  entered 
into  the  knee-joint. 

Pus  may  reach  the  ham  from  the  buttock  or  pelvis 
by  following  the  great  sciatic  nerve,  or  may  extend 
from  the  thigh  through  the  opening  in  the  great 
adductor  for  the  femoral  vessels. 

The  hamstring  muscles  are  frequently  found 
contracted  in  neglected  cases  of  knee-joint  disease,  and 
produce  thereby  more  or  less  rigid  flexion  of  the  leg 
upon  the  thigh.  Among  the  reasons  for  this  contrac- 
tion may  be  mentioned  the  fact  that  these  muscles 
are  all  supplied  by  the  gi'eat  sciatic  nerve,  and  that 
the  knee-joint  derives  its  main  nerve-supply  from 
the  same  trunk  by  means  of  its  internal  popliteal 
branch. 

Contraction  of  these  muscles  in  knee-joint  disease 
tends  not  only  to  flex  the  knee  but  also  to  draw  the 


Chap,  xxi.]         THE  POPLITEAL  SPACE.  475 

tibia  backwards,  and  produce  in  some  cases  a  partial 
luxation. 

The  hamstring  tendons  may  be  ruptured  by 
violence,  the  tendon  most  frequently  torn  being  that 
of  the  biceps.  The  muscles  are  greatly  stretched  when 
the  trunk  is  bent  forcibly  forwards  at  the  hip  joint, 
the  knee  remaining  extended.  Extreme  movement  in 
this  position  has  ruptured  some  of  the  fibres  of  this 
muscle.  The  difficulty  experienced  in  touching  the 
toes  with  the  fingers  while  the  knees  are  kept  stiff 
depends  upon  the  resistance  offered  by  the  stretched 
hamstrings.  In  tenotomy  of  the  biceps  tendon  the 
peroneal  nerve  is  in  great  risk  of  being  wounded.  It 
may  be  noted  that  contraction  of  the  muscle  tends  to 
increase  the  distance  between  the  tendon  and  the 
nerve,  and  to  render  the  former  more  superficial.  The 
peroneal  nerve  is  in  still  greater  risk  of  being  wounded 
in  resecting  the  head  of  the  fibula,  an  operation,  how- 
over,  that  is  seldom  performed. 

The  vessels  of  the  ham. — The  popliteal  vessels 
are,  from  their  depth,  but  seldom  wounded.  It  must 
be  borne  in  mind  that  the  lower  part  of  the  artery  may 
be  reached  from  the  anterior  aspect  of  the  leg  by  an 
instrument  passing  between  the  tibia  and  fibula. 
Thus  Spence  reports  the  case  of  a  farmer  who  received 
a  wound  in  front  of  the  leg,  just  below  the  knee,  from 
the  slipping  of  his  knife  while  cutting  a  stick.  It  was 
discovered  subsequently  that  the  knife  had  entered  the 
intei-osseous  space  and  had  wounded  the  popliteal 
artery  at  its  bifurcation.  It  had  indeed  nearly  severed 
the  anterior  tibial  artery  from  the  main  trunk. 

The  popliteal  artery  has  been  ruptured  by  external 
violence,  as  when  a  wheel  has  passed  over  the  region 
of  the  vessel.  Mr.  Harrison  Cripps  (Lancet,  1876) 
believes  that  the  rupture  is,  as  a  rule,  the  result  of  a 
force  acting  in  an  oblique  direction  from  below  upwards 
upon  the  lower  expanded  end  of  the  femur.  This 


476  SURGICAL  APPLIED  ANATOMY,  [dhap. xxi. 

artery  is  more  frequently  the  seat  of  aneurism  than  is 
any  other  artery  in  the  body,  save  only  the  thoracic 
aorta.  In  551  cases  of  spontaneous  aneurism,  col- 
lected by  Crisp,  the  popliteal  vessel  was  the  seat  of  the 
disease  in  137  instances,  the  thoracic  aorta  having 
been  affected  in  175  of  the  cases.  This  marked 
disposition  to  aneurism  depends  upon  many  factors. 
The  vessel  is  subjected  to  a  great  deal  of  movement, 
and  often  to  very  violent  movement.  Experiments 
upon  the  dead  body  show  that  the  inner  and  middle 
coats  of  the  vessel  may  be  ruptured  by  extreme 
flexion  of  the  knee,  and  that  a  like  rupture  may  in  a 
smaller  percentage  of  cases  be  brought  about  by 
forcible  extension.  Moreover,  except  when  the  limb 
is  in  the  position  of  extension  the  nopliteal  artery  is, 
like  the  thoracic  aorta,  much  curved.  Then,  again, 
the  vessel  breaks  up  into  two  large  vessels,  and  it  is 
well  known  that  the  point  of  bifurcation  of  an  artery 
is  a  favourite  spot  for  aneurism.  Lastly,  the  artery  is 
supported  only  by  the  lax  tissue  of  the  popliteal  space, 
and  the  support  of  strong  muscles  given  elsewhere 
to  so  many  large  vessels  is  practically  absent.  Some 
popliteal  aneurisms  have  been  successfully  treated  by 
flexing  the  knee  and  retaining  the  limb  for  some  time 
in  that  position.  That  flexion  can  have  a  direct  effect 
upon  the  lumen  of  the  vessel  is  shown  by  the  dimi- 
nished pulse  at  the  inner  ankle  produced  by  forcibly 
bending  the  leg  upon  the  thigh.  The  artery  and  vein 
are  so  adherent  that  it  is  difficult  to  separate  the  two 
when  applying  a  ligature  to  the  arterial  trunk.  This 
adhesion  must  have  been  appreciated  by  any  who 
have  taken  pains  to  "  clean  "  the  artery  in  a  dissection 
of  the  ham. 

The  popliteal  vein  is  a  remarkably  substantial 
vessel,  and  has  walls  so  dense  and  thick,  that  on 
section  they  often  look  more  like  the  tunics  of  an 
artery.  On  the  ground  of  this  peculiarity,  and  of 


chap,  xxi.i        THE  POPLITEAL  SPACE.  477 

its  close  adhesion  to  its  companion  vessel,  Tillaux 
asserts  that  "it  is  unlike  any  other  vein  in  the 
economy."  It  is  worthy  of  note  that  the  vein, 
although  more  superficial  than  the  artery,  is  very 
rarely  ruptured  by  violence.  As  a  rule,  the  artery 
alone  is  torn.  In  a  few  cases  both  the  vessels  may 
suffer ;  but  I  can  find  no  instance  recorded  of  rupture 
of  the  popliteal  vein  alone. 

From  the  relations  of  the  artery  to  the  vein  and 
nerve  it  will  be  understood  that  a  popliteal  aneurism 
may  soon  lead  to  oedema  of  the  leg  and  to  nerve 
symptoms  depending  upon  pressure  on  the  internal 
popliteal  trunk.  It  has  more  than  once  also  made  its 
way  into  the  knee-joint,  with  the  posterior  ligament 
of  which  the  artery  is  in  such  close  relation. 

The  short  saphenous  vein  lies  almost  in  the  middle 
line,  and  not  being  usually  apparent  through  the 
skin,  may  be  divided  in  an  incision  made  into  the 
lower  part  of  the  popliteal  space.  Herapat  has 
suggested  that  varices  of  this  vein  may  depend 
upon  the  narrowness  of  the  opening  in  the  fascia 
lata  through  which  the  vessel  passes  to  reach  the 
main  trunk 

The  lymphatic  glands  in  the  ham  are  from 
four  to  five  in  number  and  are  deeply  placed  about 
the  great  vessels.  When  enlarged  they  have  been 
mistaken  for  aneurism  and  -other  popliteal  tumours. 
They  receive  the  deep  lymphatics  of  the  leg.  A 
small  gland  is  often  met  with  beneath  the  fascia, 
close  to  the  point  of  entry  of  the  short  saphenous 
vein.  It  receives  some  lymphatics  that  follow  that 
vessel. 

The  biirsse  about  the  ham  are  usually  six  in 
number,  two  on  the  inner  side  of  the  space  and  four 
on  the  outer.  Inner  side. — (1)  A  large  bursa  between 
the  internal  condyle  of  the  femur  and  the  inner  head 
of  the  gastrocnemius  and  the  semimembranosus. 


478  SURGICAL  APPIJRD  AXATOMY.  [Chap.  xxi. 

This  is  the  largest  bursa  in  the  space,  and  after  adult 
life  it  usually  communicates  with  the  joint.  It  is,  of 
all  the  bursae  in  this  region,  the  one  most  often 
enlarged,  and  when  affected  may  attain  great  size. 
In  one  reported  case  the  sac  measured  5  inches  by  3 '5 
inches.  In  the  extended  position  of  the  limb  the 
enlarged  bursa  feels  firm  and  resisting,  but  on  flexion 
it  becomes  flaccid  and  can  often  be  made  to  entirely 
disappear.  Probably  the  slit  -  like  communication 
between  the  bursa  and  the  joint  is  closed  when  the 
posterior  ligament  is  tightened  by  extension,  and  is 
opened  when  it  is  relaxed  on  bending  the  knee.  In 
the  latter  posture  the  contents  of  the  bursa  can  be 
•reduced  into  the  cavity  of  the  knee-joint,  and  so  the 
tumour  disappears.  (2)  A  little  bursa  between  the 
semimembranosus  tendon  and  the  tuberosity  of  the 
tibia.  It  never  communicates  directly  with  the  joint, 
but  has  sometimes  an  opening  into  the  bursa  just 
described.  Outer  side. — (1)  A  bursa  between  the 
popliteus  tendon  and  the  external  lateral  ligament 
that  does  not  usually  communicate  with  the  joint. 
(2)  One  between  the  popliteus  tendon  and  outer 
tuberosity  of  the  tibia,  that  is  merely  a  diverticulum 
from  the  synovial  membrane.  This  sac  may  open 
into  the  tibio-fibular  articulation,  and  so  bring  that 
cavity  in  connection  with  the  knee-joint.  (3)  A  bursa 
between  the  outer  head  of  the  gastrocnemius  and  the 
femoral  condyle.  It  is  not  constant  and  is  not  con- 
nected with  the  articulation.  (4)  A  bursa  between 
the  biceps  tendon  and  the  external  lateral  ligament 
The  peroneal  nerve  runs  across  this  sac,  a  circum- 
stance that  may  explain  some  of  the  pain  experienced 
when  the  bursa  is  enlarged. 

It  is  not  improbable  that  wounds  of  bursae  in 
this  region  containing  fluid  have  been  mistaken  for 
wounds  of  the  joint,  and  the  escaping  serum  for 
syno-via. 


Chap,  xxi.]  THE  KNEE  JOINT.  479 

The  knee-joint. — This  articulation  is  the  largest 
in  the  body.  The  joint  owes  its  great  strength  to  the 
powerful  ligaments  that  unite  the  two  component  bones, 
and  to  the  muscles  and  fasciae  that  surround  it.  It 
derives  no  strength  from  the  shape  of  the  articular 
surfaces,  since  they  are  merely  placed  in  contact  with 
one  another.  In  spite  of  its  frequent  exposure  to  in- 
jury, dislocations  at  the  knee  are  extremely  rare.  The 
lateral  ligaments  are  comparatively  feeble,  are  tense  in 
extension  and  relaxed  in  flexion.  The  laxity  of  these 
ligaments  is  such  that  partial  luxations  of  the  tibia 
are  possible  without  rupture  of  these  bands,  especially 
in  cases  where  the  joint  is  found  slightly  flexed  after 
the  accident.  The  crucial  ligaments  are  very  power- 
ful, and  are  more  or  less  tense  in  all  positions  of  the 
joint.  The  anterior  of  these  ligaments  especially 
resists  extension,  forward  displacement  of  the  tibia, 
and  rotation  inwards  of  the  leg.  The  posterior  band 
resists  flexion  and  displacement  backwards  of  the 
tibia.  In  the  movement  o,f  extension  the  tibia  slides 
a  little  forwards  and  is  rotated  a  little  outwards.  In 
flexion  that  bone  glides  backwards  and  rolls  a  little 
inwards.  Extension  generally  is  limited  by  the 
crucial  and  posterior  ligaments ;  flexion  by  the  liga- 
mentuin  patellae  and  anterior  part  of  the  capsule  in 
addition  to  the  crucial  ligaments.  The  thinnest 
part  of  the  posterior  ligament  is  the  portion  below 
the  oblique  fibres  derived  from  the  semimembra- 
nosus.  If  pus  finds  its  way  from  the  joint  into  the 
ham,  it  will  probably  escape  through  this  part  of  the 
ligament. 

In  the  contracted  knee  associated  with  fibrous 
anchylosis,  the  chief  contraction,  so  far  as  the  joint 
tissues  are  concerned,  is  in  the  posterior  ligament,  in 
the  lateral  ligaments,  and  in  the  fibrous  and  fatty 
tissue  between  the  former  ligament  and  the  posterior 
crucial  band. 


480  SURGICAL  APPLIED  ANATOMY.  [Chap.  xxi. 

The  si/novial  membrane  of  the  knee-joint  extends 
upwards  as  a  large  cul-de-sac  above  the  patella  and 
beneath  the  extensor  tendon.  This  cul-de-sac  reaches 
a  point  an  inch  or  more  alx>ve  the  upper  margin  of  the 
trochlear  surface  on  the  femur,  and  is  rendered  very 


,  4|fi // 


Fig.  45. — Vertical  Section  of  Normal  Knee-joint  (Braune). 

a,  Quadriceps ;  1.  semimembranosiis ;  c,  trastrocnemius ;   a,  posterior   crucial 
ligament ;  e,  ligamentuiu  patelht ;  /,  bursa  between  quadriceps  and  femur. 

distinct  when  the  joint  is  distended  with  fluid  (Fig. 
46).  When  the  knee  is  bent,  the  cul-de-sac  is  drawn 
down,  and  therefore  this  position  of  the  limb  is 
advised  when  operations  ai-e  about  to  be  performed 
upon  the  lower  end  of  the  femur.  Above  the  sy  no  vial 
pouch  is  a  bursa  that  separates  the  quadriceps  tendon 
from  the  femur,  and  is  usually  over  an  inch  in  its 
vertical  measurement  (Fig.  45).  From  the  exami- 
nation of  two  hundred  and  sixty  knee-joints  in  .both 
infants  and  adults  Schwartz  found  that  this  bursa 


Chap,  xxi.]  THE  KNEE  JOINT.  481 

communicated  with  the  synovia!  cavity  in  seven  cases 
out  of  ten  in  young  children,  and  in  eight  cases  out  of 
ten  in  adults. 

It  will  thus  be  seen  that  when  this  communica- 
tion exists,  a  stab  over  the  femur,  about  two  inches 
above  the  trochlear  surface  of  the  bone,  or  about 
the  same  distance  above  the  top  of  the  patella, 
when  the  limb  is  extended,  will  practically  open  the 
knee-joint. 

Cases  aro  reported  of  extravasation  of  blood  into 
this  bursa,  that,  although  at  first  limited  to  the  sac, 
have,  on  rough  handling,  extended  into  the  knee- 
joint,  a  circumstance  leading  to  the  supposition  that 
in  some  cases  the  orifice  of  communication  may  be 
very  small. 

The  crucial  ligaments,  although  more  or  less  com- 
pletely invested  by  the  synovial  membrane,  are  yet 
entirely  outside  the  synovial  cavity. 

The  upper  third  of  the  patellar  ligament  is  in 
relation  to  the  synovial  membrane,  from  which,  how- 
ever, it  is  separated  by  a  pad  of  fat.  The  lower  two- 
thirds  of  the  ligament  are  in  relation  to  the  bursa  and 
fatty  tissue  that  intervene  between  the  band  and  the 
tibia.  A  knife  passed  horizontally  backwards  at  tha 
apex  of  the  patella,  would,  when  the  limb  is  extended, 
just  miss  the  joint  line  between  the  femur  and  tibia, 
and  would  hit  the  latter  bone  (Fig.  45).  If,  how- 
ever, there  be  any  effusion  in  the  joint,  or  the  limb  be 
a  little  flexed,  a  knife  so  introduced  would  pass 
between  the  two  bones  (Fig.  46). 

Joint  disease. — Owing  to  its  superficial  position, 
the  knee-joint  is  the  articulation  that  is  most  frequently 
the  seat  of  inflammations  due  to  injury  and  exposure 
to  cold.  When  distended  with  fluid,  the  effusion  soon 
shows  itself  above  and  at  the  sides  of  the  patella,  by 
bulging  forward  the  synovial  sac,  which  is  here  more 
nearly  in  relation  to  the  surface  than  it  is  elsewhere. 
f  F—  4 


482 


SURGICAL  APPLIED  ANATOMY.  [Chap.  xxi. 


Fluctuation  is  soon  to  be  detected,  and  the  patella, 
being  pushed  away  from  the  femur,  is  said  to  "  float  " 
upon  the  distending  fluid  (Fig.  46). 

The  inflamed  knee-joint,  if  left  to  itself,  almost 


**    «HmHBBBHPHHHflHMOBJL-^v» 

Fig.  46. — Vertical  Section  of  Kuee- joint  distended  with  Fluid 
(Braune). 


invariably  assumes  the  flexed  position.  This  may  be 
explained  upon  three  hypotheses,  and  it  is  probable 
that  each  of  the  three  reputed  factors  takes  part  in 
producing  this  position  in  cases  of  disease. 

(1)    The   capacity  of   the  joint   is   increased   on 


Chap,  xxi.]  THE  KNEE  JOINT.  483 

flexion.  The  pain  of  acute  synovitis  is  due  mainly 
to  the  increasing  distension  of  the  joint  with  fluid, 
and  it  is  natural  that  the  patient  should  in- 
stinctively place  the  limb  in  the  position  in  which 
the  joint  will  hold  the  greatest  amount  of  fluid, 
and  in  which  the  interarticular  tension  is  reduced 
to  a  minimum.  It  cannot  be  said,  however,  that  the 
greater  the  degree  of  flexion  the  greater  the  capa- 
city of  the  joint  cavity.  By  experimental  injections 
into  the  knee,  Braune  found  (a)  "  that  the  capacity  of 
the  synovial  cavity  reaches  its  maximum  in  a  definite 
degree  of  flexion,  and  that  the  angle  at  which  this 
happens  is  twenty-five  degrees  ;  "  (b)  that  "  the  mini- 
mum of  the  capacity  of  the  synovial  cavity  coincides 
with  the  maximum  of  flexion."  Thus  it  happens  that 
the  tension  within  an  inflamed  knee  will  be  greater  in 
extreme  flexion  than  it  is  in  full  extension. 

(2)  By  flexing  the  limb,  the  more  powerful  liga- 
ments (such  as  the  ligamentum  posticum,  the  posterior 
crucial  and  lateral  ligaments)  are  relaxed,  while  the 
ligaments   rendered    tense   by   the   position   are   the 
patellar  and  the  anterior  part  of  the  capsular,  the 
latter  of  which  is  but  a  yielding  membrane. 

(3)  The  sensory  nerves  of  the  joint  being  disturbed, 
contraction  of  muscles  may  be  anticipated  from  reflex 
action,  and  of  the  muscles,  so  excited  the  flexors  may 
be  expected  to  have  the  advantage,  as  being  the  more 
powerful  and  the  more  favourably  placed  for  acting 
upon  the  articulation. 

Dislocation  of 'the  semi-lunar  cartilages.— 
One  or  other  of  these  cartilages  may  be  displaced  from 
its  attachments  to  the  tibia,  and  become  nipped  or 
locked  between  that  bone  and  the  femur.  The  result 
is  a  sudden  pain  in  the  limb  associated  with  a  fixing  of 
the  knee  in  the  flexed  position.  The  accident  is 
usually  brought  about  by  a  twist  given  to  the  leg  when 
the  knee-joint  is  more  or  less  bent.  It  may  be  noted 


484  SURGICAL  APPLIED  ANATOMY.  [Chap,  xxi 

in  connection  with  the  causation  of  the  lesion,  that  in 
flexion  and  extension  the  two  cartilages  move  with  the 
tibia  upon  the  femur,  but  in  the  rotation  movements 
of  the  leg  one  or  other  disc  is  fixed,  and  the  tibia 
rotates  beneath  them.  Dr.  Scott  Lang  has  shown 
that  the  internal  cartilage  is  very  much  more  fre- 
quently luxated  than  is  the  external.  He  has  pointed 
out  that  displacement  of  the  internal  disc  occurs 
through  violence  applied  when  the  leg  is  rotated  out- 
wards, while  displacement  of  the  external  cartilage 
can  only  occur  when  the  leg  is  rotated  inwards. 
"  Rotation  outwards  is  performed  chiefly  by  the  biceps  ; 
consequently,  when  this  movement  is  taking  place,  the 
tibia  will  be  found  to  be  held  closely  to  the  external 
condyle  of  the  femur,  and  the  outer  cartilage  is  thus 
held  firmly  in  its  place  between  the  two  bones.  But 
the  gap  between  the  internal  condyle  and  the  tibia 
will  be  increased,  and  the  movable  cartilage  is  apt 
to  slip  between  the  internal  condyle  and  the  corre- 
sponding part  of  the  tibia.  When  the  tibia  is  rotated 
inwards  the  internal  cartilage  is  held  in  like  manner 
between  the  bones  by  the  internal  rotators,  while 
the  gap  between  the  external  condyle  and  the  tibia  is 
increased "  (Scott  Lang).  The  external  cartilage  is 
smaller  than  the  internal,  is  rounder,  is  more  movable, 
and  possibly  on  these  accounts  is  less  likely  to  be 
"nipped  "  between  the  bones. 

Gcim-valgiim,  or  knock-knee. — The  appearances 
produced  by  this  affection  are  familiar.  When  a  person 
stands  erect  with  the  feet  together,  the  tibise  are  practic- 
ally vertical,  and  the  femora  meet  them  ata  certain  angle. 
The  degree  of  this  angle  depends,  in  normal  subjects,  to 
a  great  extent  upon  the  relative  width  of  the  pelvis. 
In  genu-valgum,  the  tibise  cease  to  be  vertical  in  the 
erect  position  ;  their  lower  ends  deviate  more  and  more 
from  the  middle  line,  until  the  distance  between  the 
two  nialleoli  becomes  considerable  when  the  individual 


Chap,  xxi.]  THE  A'KEE  JOINT.  485 

stands  upright  and  when  he  is  not  concealing  any  of 
the  deformity  by  rotating  the  limb. 

The  progress  of  genu-valgum  may  be  divided  into 
three  stages.  In  the  first  stage  there  is  a  yielding  or 
elongation  of  the  internal  lateral  ligament,  and  of  the 
fascial  structures  on  the  inner  side  of  the  joint.  That 
the  yielding  of  this  ligament  alone  will  permit  of  a 
lateral  movement  at  the  articulation  being  accomplished 
is  illustrated  by  cases  of  sprains  of  the  knee,  where  the 
ligament  has  been  torn,  and  where  much  lateral  bend- 
ing has  been  in  consequence  permitted.  It  is  probable 
that  the  crucial  ligaments  yield  also  a  little,  and  it  is 
upon  the  posterior  band  attached  to  the  internal  con- 
dyle  that  the  strain  possibly  first  comes.  In  the 
second  stage  there  is  a  contraction  of  the  tissues  on  the 
outer  side  of  the  joint,  that  have  been  relaxed  by  the 
new  position  of  the  limb.  These  structures  are  the 
ilio-tibial  band  of  the  fascia  lata,  the  external  lateral 
ligament,  and  the  biceps  tendon.  This  contraction 
tends  to  give  permanency  to  the  deformity.  In  the 
third  stage  the  bones  become  changed.  On  the  outer  side 
of  the  joint  the  external  condyle  and  the  outer  tuber- 
osity  of  the  tibia  are  pressed  together,  and  through  these 
bones  the  greater  part  of  the  weight  of  the  body  will 
be  transmitted.  As  a  result  of  the  continual  pressure 
the  parts  waste  a  little,  and  by  their  atrophy  contribute 
not  only  to  the  extent  of  the  deformity  but  also  to  its 
permanency.  On  the  inner  side  the  internal  condyle 
tends  to  become  separated  from  the  tibia,  and  an 
interval  to  develop  between  the  two  bones  as  the 
deformity  advances.  This  interval  is  prevented 
from  actually  existing  by  the  development  of  the 
condyle,  which  enlarges,  and  so  still  maintains  its  con- 
tact with  the  tibia.  Mikulicz  has  pointed  cut  that 
"  the  alteration  in  length  on  the  inner  side  of  the 
femur  arises  not  from  alteration  of  the  epiphysis,  but 
is  COD  fined  to  the  lowest  part  of  the  diaphysis."  This 


486 


SURGICAL  APPLIED  ANA  TOMY.  [Chap.  xxi. 


is  shown  in  the  diagram  (Fig.  47),  where  it  will  be 
seen  that  the  enlargement  of  the  internal  condyle 
is  due  almost  entirely  to  increased  growth  in  the 
cliaphysis. 

The  patella. — Fractures. — This  bone  is  moi-e 
often  broken  by  muscular  violence  than  is  any  other 
in  the  body.  Although  the  patella  may  be  fractured 


Fig.  47. — A,  Normal  femur ;  B,  femnr  in  an  advanced  case  of  knock-knee, 
showing  the  enlargement  of  the  internal  condyle.  The  dotted  line 
in  each  case  represents  the  line  of  the  epiphysis. 

by  both  muscular  and  direct  violence,  it  would  appear 
that  the  former  is  the  agent  that  most  often  pro- 
duces the  lesion.  Thus,  in  127  cases  of  simple  trans- 
verse fracture  collected  by  Hamilton,  he  considers  that 
muscular  action  was  the  cause  of  the  injury  in  106  in- 
stances. The  form  of  fracture  due  to  muscular  violence 
is  very  uniform.  It  is  nearly  always  transverse,  simple, 
and  through  the  centre  of  the  bone,  or  just  above  that 
point  or  just  below  it.  Fractures  due  to  direct  violence 
may  present  the  same  appearance,  but  they  are  more 
often  starred,  or  oblique,  or  eAren  longitudinal.  Ex- 
periments upon  the  cadaver  show  that  a  simple  trans- 
verse fracture  about  the  centre  of  the  bone  cannot  be 
produced  with  any  degree  of  certainty  by  a  direct 
blow.  The  position  of  the  knee  that  most  favours 


chap,  xxi.]     THE  REGION  OF  THE  KNEE. 


487 


fracture  by  muscular  action  is  that  of  flexion.  When 
the  knee  is  bent,  the  patella  rests  upon  the  femoral 
conclyles  along  its  transverse  axis  only.  Nearly  the 
whole  of  its  upper  half  is  unsupported  behind,  and 
the  extensor  muscle  acts  in  a  line  nearly  at  right 
angles  to  the  vertical  axis  of  the  bone.  Thus,  by 
violent  contraction  of  the  quadriceps,  the  patella  may 
be  snapped  across  the  condyle 
as  a  stick  is  snapped  across 
the  knee  (Fig.  48).  As  the 
fracture  usually  causes  the 
patient  to  fall,  it  has  been  sup- 
posed that  the  contact  with  the 
ground,  rather  than  any  pre- 
vious muscular  action,  may 
have  caused  the  lesion.  But, 
as  Hamilton  has  pointed  out,  Fig<  ^.-Diagram  to  show 

if   a  person  falls  upon  the  bent       Mechanism  of  Fracture  of 
.,        i-     i        i         •          the  Patella   by  muscular 

knee    when    the   limb   also   is      action. 

a    vs.A  4-V.^      4i.,ml~      4-1^    «t  Line  of  action  of  quadriceps 

flexed    upon    the    trunk,    the       m,,8cie ; ».  femur ;  c,  tibia. 
part   that     comes     in    contact 

with  the  ground  is  not  the  patella,  but  the  tubercle 
of  the  tibia. 

In  the  great  majority  of  cases,  the  lesion  not  only 
involves  the  bone,  but  also  the  cartilage  and  fibrous 
structures  that  cover  it  respectively  behind  and  in 
front ;  the  synovial  membrane  also  is  torn,  and  the 
patellar  bursa  opened  up.  Thus  the  synovial  contents 
may  come  in  actual  contact  with  the  skin.  "  It  is 
anatomically  possible,  if  the  fracture  involve  only  the 
lower  and  non-articular  portion  of  the  patella,  and  if 
the  amount  of  separation  of  the  fragments  is  slight, 
that  the  fatty  tissue  behind  the  apex  of  the  patella, 
over  which  the  synovial  membrane  is  reflected,  may 
save  the  latter  from  injury  "  (Henry  Morris).  In  all 
cases  where  there  is  much  separation  of  the  fragments, 
the  fibrous  expansion  attached  to  either  side  of  the 


4S8  Srxc/CAL  APPLIED  ANATOMY.  [Oup.  xxi 

patella  must  be  torn  through.  Indeed,  none  but  a 
slight  separation  of  the  parts  is  possible  until  that  ex- 
pansion is  ruptured.  Braune  has  demonstrated  this 
by  experiment,  by  sawing  through  the  patella  without 
damage  to  the  lateral  ligamentous  structures,  and 
noting  that  but  trifling  separation  of  the  fragments 
was  possible  until  these  structures  had  been  divided. 
In  stellate  fractures,  due  to  direct  violence,  these 
fibrous  expansions  from  the  extensor  tendon  may  be 
uninjured,  and  no  separation  of  any  magnitude  be  per- 
mitted between  the  portions  of  the  broken  bone. 

The  patella  is  more  readily  broken  by  muscular 
violence  than  is  either  the  extensor  tendon  or  the  liga- 
nientum  patellae.  In  the  flexed  position  it  will  be  seen 
(Fig.  48)  that  the  bone  is  placed  at  a  considerable 
disadvantage  when  compared  with  the  two  other 
structures.  Richet  reports  a  case  where  violent  con- 
traction of  the  quadriceps  caused  the  tubercle  of  the 
tibia  to  be  torn  away  from  the  bone  without  any  other 
lesion  of  the  parts  immediately  concerned  being 
produced. 

Dislocation  of  the  patella. — This  bone  may 
be  dislocated  outwards  or  inwards,  or  turned  upon  its 
edge  so  that  its  anterior  and  posterior  surfaces  are 
placed  laterally.  The  luxation  outwards  is  by  far  the 
most  common.  This  depends  upon  the  fact  that  the 
quadriceps,  the  patella,  and  the  ligamentum  patellae  do 
not,  when  the  muscle  is  contracted,  follow  the  lines  of 
the  femur  and  tibia.  They  are  more  nearly  in  a 
straight  line,  that  pass-as  to  the  outer  side  of  the  angle 
formed  by  the  femur  with  the  leg  at  the  knee-joint 
Muscular  contraction,  therefore,  tends  to  draw  the 
knee-cap  outwards,  a  tendency  that  is  in  all  normal 
circumstances  corrected  by  the  increased  prominence 
of  the  external  condyle.  The  vastus  externus  also  is 
said  to  be  more  powerful  than  the  internus. 

Dislocations    of    this    bone    are    usually    due    to 


chap,  xxi.]     THE  REGION  OF  THE  KNEE. 


489 


muscular  action,  and  are  most  apt  to  occur  in  the  ex- 
tended position  of  the  limb,  the  position  in  which  the 
patella  is  not  fixed  and  its  ligament  and  the  anterior 
part  of  the  joint 
capsule  attached 
to  the  bone  are 
the  most  lax.  The 
lateral  luxations  are 
usually  incomplete, 
but  may  be  com- 
plete. In  the 
former  case  the  an- 
terior part  of  the 
capsule  need  not  be 
torn,  but  in  the 
latter  form  it  can 
scarcely  escape  ex- 
tensive rupture. 

In   the   disloca- 
tion of  the  patella 

upon    its    edge,    the     Figr..49.-Tmnsveree  Section 

.  *          ,  a  joint  through  the  centre  of  the 

inner  boi'der  of  the  (Braune). 
bone  usually  pro- 
jects forwards,  while 
the  outer  is  placed 
between  the  con- 
dyles.  But  little 
is  known  as  to  the  mechanism  of  this  dislocation. 

In  dislocations  of  the  knee,  which  are  very 
rare,  the  tibia  may  be  displaced  outwards,  inwards, 
forwards,  or  backwards.  The  two  lateral  luxations 
appear  to  be  more  common  than  the  antero-posterior. 
The  former  are  nearly  always  partial,  the  latter  usually 
complete.  Considerable  violence  is  required  to  produce 
these  luxations,  owing  to  the  great  strength  of  the 
ligaments  and  the  great  width  of  the  bones  involved. 
Direct  violence  to  the  tibia  or  femur,  associated  often 


a,  Patellae  Imrsn  ;  ft,  internal  lateral  ligament  ami 
inner  condylc ;  c.  external  Intend  ligament 
and  outer  romlyle;  d,  liireps;  e,  seiiiiiuem- 
brannsus;  /.  seniitemlinosiis ;  g.  grnrilis 
tendon;  h,  sartorius;  1,  internal  popliteal 
nerve;  external  popliteal  nerve;  3,  internal 
saplienous  vein. 


49°  SiwcrcAL  APPLIED  ANA  TOMY.  iciiap.  xxi 

with  a  twisting  of  the  former  bone,  is  the  common 
cause  of  the  lesion.  It  is  probable  that  in  all  luxa- 
tions of  the  knee,  the  crucial  ligaments  are  torn. 
The  lateral  ligaments  also  are  usually  ruptured,  but  in 
the  partial  luxations  they  may  be  sometimes  found  to 
be  intact.  The  tendinous  expansion  of  the  vasti  in 
front  of  the  knee  seldom  escapes  some  laceration,  even 
in  the  partial  dislocations.  The  projection  of  the  spine 
of  the  tibia  between  the  femoral  condyles  offers  an 
obstruction  to  lateral  luxation.  In  the  autero-posterior 
displacements,  the  tibia  is  more  often  luxated  forwards 
than  backwards.  In  these  injuries,  not  only  are  the 
crucial  and  lateral  ligaments  torn,  together  with  the 
anterior  part  of  the  capsule,  but  the  posterior  ligament, 
the  gastrocnemius,  the  biceps,  and  less  often  the  semi- 
membranosus,  suffer  more  or  less  extensive  laceration. 
The  popliteal  vessels  and  nerves  are  much  compressed, 
and  appear  to  be  more  severely  injured  by  the  femur 
in  the  forward  dislocation  than  by  the  tibia  in  the 
backward  displacement. 

The  lower  end  of  the  femur. — The  conclylar 
part  of  the  femur  is  composed  almost  wholly  of  can- 
cellous  bone,  with  but  a  slight  layer  of  compact  tissue. 
It  is  so  spongy  that  it  may  be  pierced  by  a  bullet,  as 
pointed  out  by  Legouest,  without  any  splintering  of 
the  bone  being  produced,  and  without  damage  to  the 
articulation.  The  fractures  that  may  be  met  with  in 
the  lower  end  of  the  bone  are  the  following :  (1)  A 
fracture  of  the  shaft  above  the  condyles ;  (2)  a  sepa- 
ration of  the  lower  epiphysis ;  (3)  a  fracture  separating 
either  the  outer  or  inner  condyle  ;  (4)  a  T-shaped 
fracture,  i.e.,  a  transverse  fracture  above  the  condyles 
with  a  vertical  one  between  those  processes.  These 
lesions  are,  as  a  rule,  due  to  well  localised  direct  vio- 
lence. Fractures  Nos.  1  and  4  may  be  produced  by  in- 
direct violence,  as  by  a  fall  upon  the  feet  from  a  height. 
Henry  Morris  states  that  lateral  flexion,  or  forw 


Chap,  xxi.]      THE  REGION  OF  THE  KNEE.  491 

applied  in  a  lateral  direction,  is  best  calculated  to  pro- 
duce a  separation  of  the  epiphysis.  Hamilton  reports 
a  strange  case  in  a  man  aged  21,  whose  outer  condyle 
was  fractured  by  the  twist  of  the  leg,  which  happened 
while  he  was  undressing  himself  to  bathe.  The  only 
fracture  that  requires  special  notice  in  this  place  is  the 
fracture  of  the  shaft  just  above  the  condyles.  The 
lesion  is  situated  generally  about  two  inches  above  the 
line  of  the  epiphysis,  and  corresponds  to  the  spot 
where  the  compact  shaft  joins  the  softer  and  more 
cancellous  tissue  of  the  lower  end  of  the  bone.  It  is 
near  the  place,  also,  where  the  femoral  artery  crosses 
the  bone  to  reach  the  ham,  and  it  has  thus  happened 
that  the  vessel  has  been  wounded  by  splinters  in  this 
particular  injury.  The  fracture  is  usually  obliqtie, 
from  behind,  downwards,  and  forwards.  The  lower 
fragment  will  be  drawn  upwards  by  the  same  muscles 
that  produce  shortening  in  other  fractures  of  the  sbaft 
(page  466).  and  its  sharp  upper  end  is  very  apt  to  be 
pulled  forcibly  into  the  popliteal  space  by  the  gastroc- 
nemius  muscle.  This  latter  displacement  is  difficult  to 
remedy.  If  the  limb  be  extended,  the  fragment  is 
only  drawn  the  more  into  the  ham,  and  it  is  therefore 
possible  for  the  limb  to  appear  straight,  and  yet  have 
the  knee-joint  much  bent.  In  several  cases  of  this 
injury  I  divided  the  tendo  Achillis,  and  then  placed 
the  limb  upon  a  straight  splint,  following  a  practice 
suggested  by  Mr.  Bryant.  The  effect  upon  the  posi- 
tion of  the  fragments  was  in  each  case  very  good 
(Brit.  Med.  Jour.,  1883). 

The  upper  end  of  the  tibia  is  sometimes  the 
seat  of  fracture,  although  of  all  parts  of  this  bone 
the  upper  third  is  the  part  least  often  broken.  One 
or  other  of  the  tuberosities  may  be  broken  off,  or 
there  may  be  a  transverse  or  oblique  fracture  of  the 
upper  end  of  the  shaft  associated  with  a  vertical 
one  running  up  into  the  joint  between  the  two 


492  SURGICAL  APPLIED  AIVATOMY.  [Chap.  xxi. 

tuberosities.  Such  accidents  are  the  result,  in  nearly 
every  instance,  of  great  direct  violence.  Dr.  Hutton 
reports  a  case,  probably  unique,  in  which  the  spine  of 
tibia,  the  central  part  of  the  head  of  the  bone,  and  a 
considerable  portion  of  the  left  articular  surface,  were 
torn  from  the  rest  of  the  tibia.  The  anterior  crucial 
ligament  was  attached  to  the  fragment.  The  patient 
had  been  wrestling  while  in  a  state  of  intoxication, 
and  had  been  heavily  thrown.  Madame  Lachapelle 
reports  a  case  of  separation  of  the  upper  epiphysis  of 
the  tibia  caused  by  traction  during  parturition ;  but  I 
am  not  aware  of  any  reported  case  of  separation  of 
this  epiphysis  due  to  violence  or  under  circumstances 
,other  than  this. 

The  spongy  tissue  in  the  head  of  this  bone  and  in 
the  lower  end  of  the  femur  is,  par  excelh'iice,  the 
favourite  seat  for  myeloid  sarcomata. 

In  excising  the  knee-joint  through  an  inci- 
sion commencing  at  the  back  of  one  condyle,  and 
continued  across  the  joint,  just  below  the  patella,  to 
the  back  of  the  other  condyle,  the  following  structures 
are  divided  :  Skin,  fascia,  patellar  plexus  of  nerves 
(formed  by  the  middle  and  internal  cutaneous  and 
the  patellar  branch  of  the  long  saphenous),  bursa 
patellae,  anterior  part  of  the  capsule,  ligamentum 
patellae,  synovial  membrane,  lateral  and  crucial  liga- 
ments, the  superior  and  inferior  articular  arteries, 
the  anastomotica  magna,  and  the  anterior  tibial 
recurrent  vessel. 

The  incision  over  the  inner  condyle  need  not  be 
made  so  far  back  as  to  divide  the  internal  saphenous 
vein  and  nerve.  In  sawing  the  femur  it  is  most 
important  that  the  exact  inclination  of  the  joint 
surface  of  the  bone  be  reproduced.  If  improperly  sawn 
the  patient  would  be  bow-legged  or  knock-kneed.  The 
rule,  therefore,  is  that  the  saw  be  applied  parallel  to 
the  articular  surface  and  perpendicular  to  the  shaft 


chap,  xxi.]     THE  REGION  OF  THE  KNEE, 


493 


In  young  subjects  care  must  be  taken  that  the 
saw-cut  do  not  pass  beyond  the  epiphyseal  line.  The 
upper  limit  of  the  femoral  e]nphysis  will  be  repre- 
sented by  a  horizontal  *me  drawn  across  the  bone  at 
the  level  of  the  tubercle  for  the  adductor  magnus. 
If  the  whole  of  the  trochlear  surface  be  removed  in  the 
excision,  the  whole  of  the  epiphysis  will  have  been 
taken  away.  A  single  nucleus  appears  in  this 
epiphysis  shortly  before  birth,  and  joins  the  shaft 
about  the  twentieth  year.  The  limits  of  the  tibicd 
epiphysis  are  represented  behind  and  at  the  sides  by  a 
horizontal  line  that  just  marks  oft'  the  tuberosities. 
It  includes,  therefore, 
the  depression  for  the 
insertion  of  the  semi- 
membranosus,  and  also 
the  facet  for  the  fibula. 
In  front  the  epiphyseal 
line  slopes  downwards 
on  either  side  to  a 
point  on  the  upper  end 
of  the  shin,  so  as  to  en- 
close the  whole  of  the 
tubercle  of  the  tibia. 
The  centre  joins  the 
main  bone  at  the  twen- 
ty-firstor  twenty-second 
year.  The  popliteal 
artery  runs  some  risk 
of  being  wounded  in 
this  procedure.  The 
vessel  is  separated  by 
some  little  distance  from 
the  popliteal  surface  of 
the  femur  (Fig.  49), 
but  is  in  very  close  relation  to  the  tibia,  the  pos- 
terior ligament  alone  intervening  at  the  upper  level  ot 


Y 


Fig.  50.— Disarticulation  at  the  Knee- 
joint  by  siugle  Anterior  Flap 
(Agutz). 

a,  Int.  rondylc;  *.  ext.  condyle;  c,  intor- 
condyloid  fossa;  d,  ligr.  patellae;  e,  sar- 
toriiis;/,  gracilis ;  </,  seniitendiuosiis; 
A,  cxt.  lat.  ligament;  i,  popliteiis:  >, 
plantaris  :  fc,  geminieiubranostis  ;  '  and 
m,  inner  head  of  gastrocncniiiig;  », outer 
head  of  gutroenemias ;  o,  biceps;  p, 
popliteal  vessels;  q,  int.  pop.  nerve. 


494  SURGICAL  APPLIED  ANA TOMY.  [Chap.  xxn. 

the  bone.  It  thus  happens  that  the  risk  of  wounding  the 
artery  is  greater  when  the  tibia  is  sawn  than  when  the 
lower  part  of  the  femur  is  being  removed.  Excision  of 
the  knee  is,  to  a  large  extent,  replaced  by  arthrectomy. 
Amputation  through  the  knee-joint. — By 
single  anterior  flap.  In  fashioning  the  anterior  flap 
(which  is  composed  only  of  integument),  and  in 
opening  the  joint,  the  patellar  plexus  of  nerves,  the 
superficial  branches  of  the  plexus  of  arteries,  the 
ligamentum  patellae,  and  the  anterior  part  of  the 
capsule  will  be  cut.  Nearer  the  condyles  of  the  femur 
the  anastomotic  and  the  two  superior  articular  arteries 
will  be  divided.  The  long  saphenous  vein  and  nerve 
will  be  divided  at  the  inner  angle  of  the  flap.  On  the 
cut  surface  made  by  the  posterior  incision  will  be  found 
divided  the  sartorius,  gracilis,  and  semitendinosus,  the 
semimembranous,  both  heads  of  the  gastrocnemius, 
the  popliteus,  plantaris,  and  biceps.  The  popliteal 
vessels,  the  sural  arteries,  the  short  saphenous  vein, 
the  internal  and  external  popliteal  nerves,  the  external 
saphenous  and  the  small  sciatic  nerves  will  also  be 
found  divided  in  the  same  incision.  The  most 
convenient  amputation  at  the  knee-joint  is  by  equal 
lateral  flaps  (Stephen  Smith's  operation). 


CHAPTER  XXII. 

THE    LEG. 

Surface  anatomy. — The  anterior  border  of  the 
tibia  can  be  felt  in  its  entire  length,  forming,  as  it  does, 
the  prominence  of  the  shin.  It  should  be  remembered 
that  this  border  presents  a  somewhat  flexuous  course, 
being  cui-ved  outwards  above  and  inwards  below.  The 
broad  internal  surface  of  the  bone  is  subcutaneous, 
and  the  internal  border  can  be  followed  from  the 
tuberosity  to  the  mallcolus.  The  head  of  the 


xxii.j  THE  LEG.  495 

fibula  can  be  distinctly  made  out,  but  the  upper 
half  of  the  shaft  of  the  bone  is  lost  beneath  the 
mass  of  muscle  on  the  outer  side  of  the  limb.  The 
lower  half  of  the  fibular  shaft  can  be  felt,  and  the 
bone  just  above  the  malleolus  becomes  subcutaneous 
in  the  interval  between  the  peroneus  tertius  and  the 
two  other  peroneal  tendons.  Between  the  tibia  and 
fibula  the  outline  of  the  tibialis  anticus  muscle  can  be 
well  defined  when  it  is  in  action.  To  its  outer  side  is 
the  less  conspicuous  and  narrower  eminence  formed  by 
the  extensor  communis  digitorum.  In  well  developed 
limbs  the  groove  that  separates  these  two  muscles  is 
very  distinct,  and  forms  the  best  guide  to  the  anterior 
tibial  artery.  In  the  lower  third  of  the  leg  these 
muscles  become  tendinous,  and  between  them  the 
extensor  longus  pollicis  can  be  felt  as  it  comes  to  the 
surface.  The  long  and  short  peroneal  muscles  can  be 
defined,  and  their  tendons  followed  behind  the 
malleolus.  When  in  active  contraction  the  interval 
between  the  two  muscles  is  often  well  marked.  The 
gastrocnemius  muscle  and  the  more  superficial  parts 
of  the  soleus  are  brought  well  into  view  when  the 
body  is  raised  upon  the  toes.  The  two  heads  of  the 
former  muscle  are  then  quite  conspicuous,  and  it  can 
be  seen  that  the  inner  head  is  the  larger  and  descends 
lower  in  the  leg. 

The  popliteal  artery  bifurcates  on  a  level  with  the 
lower  part  of  the  tubercle  of  the  tibia.  The  course  of 
the  posterior  tibial  vessel  is  represented  by  a  line 
drawn  from  the  middle  of  the  limb  at  the  lower  part 
of  the  ham  to  a  spot  midway  between  the  inner 
malleolus  and  the  prominence  of  the  heel.  The 
artery  becomes  superficial  in  the  lower  fourth  of  the 
leg,  where  it  may  be  felt  pulsating  between  the  tendo 
Achillis  and  the  tibia.  The  peroneal  artery  arises 
about  three  inches  below  the  knee,  follows  the  posterior 
surface  of  the  fibula,  and  ends  behind  the  outer 


496  SURGICAL  APPLIED  ANATOMY.  [Chap. xxn. 

malleolus.  The  position  of  the  anterior  tibial  artery 
may  be  indicated  by  a  line  drawn  from  a  point  midway 
between  the  outer  tuberosity  of  the  tibia  and  the  head 
of  the  fibula  to  the  centre  of  the  front  of  the  ankle 
joint.  Both  the  saphenous  veins  can  often  be  made 
out  in  the  leg.  The  inner  or  larger  viin  passes  in 
front  of  the  malleolus  and  ascends  just  behind  the 
internal  border  of  the  tibia.  With  it  runs  the  long 
saphenous  nerve.  The  short  saphenous  vein  lies 
behind  the  outer  malleolus,  and  passing  up  the  middle 
of  the  calf  ends  at  the  ham.  It  is  accompanied  by 
the  external  saphenous  nerve. 

The  leg. — The  skin  is  somewhat  more  adherent  to 
.deeper  parts  in  the  leg  than  it  is  in  the  thigh.  The 
difference  in  the  degree  of  this  adhesion  is  obvious 
when  skin-flaps  are  dissected  up  from  the  two  parts 
in  cases  of  amputation.  Over  the  internal  surface  of 
the  tibia  and  the  greater  part  of  the  shin,  the 
integument  lies  directly  upon  the  periosteum  and 
bone,  nothing  intervening  save  a  scanty  amount  of 
subcutaneous  fascia.  Thus  blows  and  kicks  over  these 
parts  of  the  leg  are  apt  to  be  associated  not  only 
with  much  pain  but  also  with  much  bruising  or 
tearing  of  the  integument.  A  "  graze  on  the  shin  " 
is  one  of  the  commonest  of  lesions,  and  is  produced  by 
a  degree  of  violence  that  upon  a  well -covered  part 
would  have  little  or  no  effect.  It  will  be  understood 
that  ulcers  over  these  feebly  protected  parts  may, 
if  they  spread  in  depth,  readily  expose  the  bone  and 
lead  to  some  disease  of  its  substance,  or  to  at  least 
some  inflammation  of  its  periosteum.  Scars  left  by 
deep  ulcers  or  burns  are  also  often  found  to  be 
quite  adherent  to  the  bone. 

The  apoiieurosis  of  the  leg  invests  it  like  a 
tightly  -drawn  buskin,  being  lacking  only  over  the  sub- 
cutaneous surfaces  of  the  bones.  It  is  attached  to  the 
head  and  the  anterior  raid  inner  borders  of  the  tibia, 


chap,  xxii.]  THE  LEG.  497 

the  head  of  the  fibula,  and  the  two  malleoli.  It  is 
continuous  above  with  the  fascia  lata,  and  below  with 
the  fascia  of  the  foot  and  the  annular  ligaments.  It 
is  thicker  in  front  than  behind,  and  is  especially  thick 
at  the  upper  part  of  the  leg  just  below  the  knee. 
Here  the  fascia  offers  great  resistance  to  the  growth 
of  tumours  springing  from  the  head  of  the  tibia. 
From  the  deep  surface  of  the  aponeurosis  two 
septa  pass  inwards  to  be  attached  to  the  an- 
terior and  external  borders  of  the  fibula.  They 
serve  to  isolate  the  two  larger  peroneal  muscles 
from  the  other  muscles  of  the  limb,  and  form  a 
closed  space  which  might  form  a  definite  and  well 
localised  cavity  for  pus.  Beneath  the  gastrocnemius 
and  soleus  a  layer  of  fascia  extends  between  the  two 
bones  and  covers  in  the  deep  layer  of  muscles.  It 
is  thin  above  but  denser  below,  and  would  have  some 
influence  in  directing  the  progress  of  a  deep  abscess. 

In  the  upper  third  of  the  leg  there  is  a  septum  be- 
tween the  tibialis  anticus  and  extensor  communis 
digitorum,  which  must  be  found  in  the  operation  for 
ligaturing  the  upper  part  of  the  anterior  tibial  artery. 
I  have  never  had  the  good  fortune  to  see  the  very 
distinct  "white  line"  that  many  text-books  describe 
as  indicating  the  position  of  this  septum. 

In  the  substance  of  the  soleus  muscle  there  is  a 
tendinous  expansion  connected  with  the  border  of  the 
tibia,  that  runs  backwards  and  towards  the  middle 
Una  In  cutting  through  the  soleus  to  apply  a  liga- 
ture to  the  posterior  tibial  artery,  this  intersection 
may  be  mistaken  for  the  aponeurosis  on  the  deep 
surface  of  the  muscle. 

Several  cases  are  reported  of  rupture  of  some  part 
of  the  gastrocnemius  muscle  during  violent  exertion. 
The  teudo  Achillis  has  been  ruptured  under  like  cir- 
cumstances. It  is  said  that  the  plantaris  tendon  is 
also  not  infrequently  torn  across,  producing  a  sudden 

GG — 4 


408  SURGICAL  APPLIED  A  NATO  My.  rchap.  XKII. 

sharp  |«,in  in  the  calf  during  exertion,  to  which  the 
French  give  the  name  "  coup  de  fouet." 

Vessels. — The  large  arteries  of  the  leg,  being  all 
in  near  proximity  with  the  bones,  are  apt  to  be  injured 
by  sharp  fragments  in  fractures  of  the  limb.  This 
especially  applies  to  the  peroneal  artery,  which  rims 
along  the  fibula,  and  is  in  considerable  risk  of  being 
wounded  in  fractures  about  the  middle  of  that  bone. 
It  is  at  the  point  of  bifuraction  of  the  popliteal  artery 
that  emboli  are  peculiarly  apt  to  lodge.  They  plug 
the  vessel  and  practically  block  the  three  main  arteries 
of  the  leg.  Gangrene,  therefore,  not  infrequently 
follows  the  occurrence.  Billroth  states  that  in  all  the 
eases  of  gangrene  of  the  leg  due  to  embolism  that  he 
has  met  with,  the  plug  was  found  situated  at  the 
bifuraction  of  the  popliteal  trunk  ("  Clinical  Surgery," 
1881).  According  to  some  French  surgeons,  aneurism 
of  the  commencement  of  the  posterior  tibial  artery 
is  more  often  associated  with  gangrene  of  the  leg  than 
is  a  popliteal  aneurism.  The  reason  they  assign  is 
the  following :  The  aneurism  on  the  former  vessel 
not  only  interferes  with  the  passage  of  the  blood  into 
the  posterior  tibial  and  peroneal  arteries,  but  also 
compresses  the  anterior  tibial  vessel  and  with  it  the 
anterior  tibial  recurrent,  an  artery  that  is  of  so  great 
importance  in  establishing  the  collateral  circulation. 

Varicose  veins  are  more  commonly  met  with  in 
the  leg  than  in  any  other  part  of  the  body,  save,  per- 
haps, in  the  hsemorrhoidal  and  spermatic  veins.  This 
depends  upon  the  great  length  of  the  veins  of  the  lower 
limb,  the  large  columns  of  blood  their  valves  have  to 
support,  their  vertical  position,  the  liability  of  the 
great  trunks  (iliac),  into  which  they  ultimately  enter, 
to  be  compressed,  and  upon  the  fact  that  the  superficial 
veins,  being  outside  the  fascia,  lose  that  assistance  to 
the  circulation  derived  from  muscular  contraction.  The 
use  of  garters  especially  affects  the  long  saphenous  vein, 


chap,  xxii.i  THE  LEG.  499 

which  lies  close  to  the  bone  at  the  spot  about  which 
these  contracting  bands  are  usually  applied.  Between 
the  two  layers  of  the  muscles  of  the  calf  Verneuil 
describes  a  venous  plexus,  which  he  believes  to  be 
more  often  the  seat  of  varices  than  are  the  vessels  of 
the  surface.  A  varicose  condition  of  these  deeply- 
placed  veins  may  explain  the  "  aching  legs  "  complained 
of  by  those  who  stand  a  great  deal.  The  intramus- 
cular veins  are  very  large.  Callender 
showed  that  the  six  chief  veins  which 
pass  from  the  soleus  muscle  alone  to 
enter  into  the  posterior  tibial  and  pero- 
neal  trunks  have  a  united  diameter  of 
not  less  than  one  inch.  Varix  would 
appear  to  commence  most  often  at  points 
where  the  deep  veins  join  the  superficial 
vessels.  There  is  good  reason  for  this, 
for  at  these  points  three  forces  meet, 
the  general  directions  of  which  are  shown  in  the 
annexed  diagram  (Fig.  51).  There  is  the  weight  of 
the  superincumbent  column  of  blood  (a)  acting  from 
above,  the  resistance  offered  by  the  next  valve  below 
the  point  of  entry  of  the  deep  vein  acting  from  below 
(&),  and  the  force  with  which  the  blood  is  driven  by 
the  conti'acting  muscles  out  of  the  deep  vein  into  the 
superficial  trunk  acting  at  an  angle  to  both  these  lines 
of  force  (e).  Unfortunately  for  the  subjects  of  varices, 
the  two  principal  veins  (the  saphenous)  are  accom- 
panied by  sensory  nerves,  and  there  is  no  doubt  that 
much  of  the  pain  incident  to  varicose  veins  in  the  leg 
depends  upon  pressure  on  these  nerves. 

With  reference  to  pain  in  the  leg  it  must  be 
remembered  that  the  nerves  that  bring  sensation  to  the 
part  arise  at  a  considerable  distance  from  their  points 
of  termination,  and  that  the  causes  of  pain  in  the  limb 
may  be  situated  far  away  from  the  seat  of  trouble. 
Thus  Sir  B.  Brodie  mentions  the  case  of  a  gentleman 


500  SURGICAL  ATTLIED  ANATOMY.  [Chap, xxn. 

who  suffered  from  severe  pain  in  the  left  leg,  from  the 
foot  to  the  knee,  in  the  course  of  the  peroneal  nerve. 
No  cause  could  be  found  for  it.  At  the  patient's 
death,  however,  a  large  tumour  was  found  attached  to 
the  lumbar  spine,  which  had  evidently  compressed  the 
left  great  sciatic  nerve. 

There  would  appear  to  be  little  connection  between 
disease  in  the  rectum  and  a  pain  in  the  leg,  yet  in  one 
case  at  least  that  connection  was  marked.  "  Only 
recently,"  writes  Mr.  Hilton,  "I  saw  a  gentleman 
from  South  Wales,  who  was  the  subject  of  stricture 
of  the  rectum  from  malignant  disease.  He  suffered 
pain  in  the  knee-joint  and  in  the  back  part  of  the  leg. 
This  led  me  to  suspect,  what  really  turned  out,  upon 
careful  examination,  to  be  the  case,  that  a  large  mass 
of  cancer  was  involving  the  nerves  on  the  anterior 
part  of  the  sacrum,  and  also,  no  doubt,  the  obturator 
nerve." 

Dr.  Ralfe  mentions  cases  of  renal  calculus  attended 
by  severe  pain  in  the  sole  of  the  foot. 

Fractures  of  the  leg. — Of  the  bones  of  the  leg 
the  tibia  and  fibula  are  more  often  broken  together 
than  singly,  and  of  separate  bones  the  fibula  is 
more  often  fractured  than  is  the  larger  bone. 

1.  The  tibia  and  fibula.  As  regards  the  resistance 
it  offers  to  violence  the  fibula  presents  about  the  same 
degree  of  strength  in  all  its  parts,  save  at  the  malleo- 
lus  and  at  its  upper  extremity.  Its  great  length  and 
the  manner  of  its  attachment  to  the  tibia  (its  two  ends 
being  fixed  and  its  main  part  being  unsupported) 
render  it  a  slender  bone,  and  but  for  the  efficient 
protection  it  derives  from  the  thick  pad  of  muscles  that 
surrounds  it  would  no  doubt  be  very  frequently  broken. 
This  is  all  the  more  likely  to  be  the  case,  since  the  bone 
is  placed  upon  the  more  exposed  aspect  of  the  limb. 

The  shaft  of  the  tibis  presents  various  degrees  of 
strength  according  as  we  regard  its  upper,  middle,  or 


chap,  xxii.)  THE  LEG.  501 

lower  third.  According  to  Dr.  Leriche  the  average 
transverse  diameter  of  the  adult  tibia  just  below  the 
tuberosities  is  a  little  over  If  inches.  The  transverse 
diameter  at  the  base  of  the  malleolus  is  a  little  less 
than  If  inches,  and  that  of  the  narrowest  part  of  the 
bone  is  a  little  more  than  one  inch.  This  narrow 
part  is  at  the  junction  of  the  lower  with  the  middle 
third  of  the  shaft  and  is  the  weakest  point  in  the  bone. 
The  relation  of  the  compact  to  the  cancellous 
tissue  is  about  the  same  in  all  parts  of  the  shaft;  but 
according  to  MM.  Fayel  and  Duret  the  spongy 
tissue  is  arranged  in  two  independent  vertical  columns, 
one  occupying  the  upper  two-thirds  and  the  other 
the  lower  third  of  the  bone.  The  minimum 
of  resistance  (these  authors  assert)  is  at  the  point 
where  these  two  systems  meet.  Thus  it  happens 
that  the  most  common  spot  for  a  fracture  of  the  tibia 
is  at  the  junction  of  the  middle  with  the  lower  third 
of  the  shaft.  It  is  here  that  the  bone  yields  when 
broken  by  indirect  violence,  while  the  lesions  de- 
pending upon  direct  violence  may  be  at  any  part  of 
the  shaft.  Owing  to  the  thin  covering  of  soft  parts, 
and  the  slight  barrier  interposed  between  the  frac- 
turing force  and  the  bone,  it  comes  to  pass  that 
fractures  of  the  leg  are  more  often  compound  and 
comminuted  than  are  those  of  any  other  bones  of  the 
extremities.  If  the  fracture  be  oblique  (as  is  commonly 
the  case  when  the  violence  is  indirectly  applied),  the 
line  of  breakage  usually  extends  from  behind,  down- 
wards, forwards  and  a  little  inwards.  The  lower 
fragment,  with  the  foot,  is  drawn  up  behind  the  rest 
of  the  bone  by  the  muscles  of  the  calf,  and  is  usually 
displaced  also  outwards  by  the  obliquity  of  the 
fracture  line.  Often  the  lower  fragment  is  slightly 
rotated  outwards  by  the  rolling  over  of  the  foot,  a 
rotation  produced  by  the  simple  weight  of  the  limb.  If 
the  fracture  be  transverse  there  may  be  little  or  no 


502  SURGICAL  APPLIED  ANA  TOMY.  [Chap.  xxn. 

displacement.  The  fibula  is  usually  broken  at  a  higher 
level  than  the  tibia,  and  its  lower  fragment  follows,  of 
course,  with  absolute  precision  the  corresponding 
fragment  of  the  larger  bone.  A  remarkable  spiral 
fracture  (fracture  helicoi'de),  involving  the  lower  third 
of  the  tibia,  has  been  described  by  French  surgeons. 
It  is  associated  with  a  more  or  less  vertical  fissure 
that  involves  the  ankle-joint,  and  with  a  fracture  of 
the  fibula  high  up.  MM.  Leriche  and  Tillaux  have 
shown  that  this  injury  is  due  to  torsion,  especially  to 
some  twisting  of  the  leg  while  the  foot  is  fixed. 

2.  The  fibula  alone.       Fractures  of   this  bone  in 
its  lower  fourth  are  usually  due  to  indirect  violence, 
Aad    will    be    dealt   with    in    connection    with   the 
ankle-joint.     When   broken   in   any   other   part   the 
fracturing  force  is  usually  directly  applied,  the  lesion 
transverse,    and    the    displacement    insignificant,    or 
scarcely  obvious.     The  tibia  acts  as  an  efficient  splint. 

3.  The  tibia  alone.     The  malleolus  may  be  broken 
by  a  blow,   or  the  lower  epiphysis  separated.      The 
latter  comprises  the   whole  of  the  inner   malleolus, 
and  the  facet  with  which  the  fibula  articulates.     It 
joins  the   shaft  during  the  eighteenth  or  nineteenth 
year.     Fractures  of  the  tibia  alone  are  nearly  always 
due  to  direct  violence,  and  whilst  most  common  in  the 
lower  third  of   the   bone,  become  more  rare  as  the 
knee  is  approached.     When  transverse  there  may  be 
no  visible  displacement,  the  fibula  acting  as  a  splint. 
Thus  Mr.  H.   Morris  mentions  the  case  of  a  woman 
who  walked  into  and  out  of  a  hospital  with  a  trans- 
verse fracture  of  the  tibia  that  was  not  detected  on 
examination,    and   was   not   indeed  discovered   until 
two  days  after  the  accident.     When  the  fracture  is 
just  above  the  ankle  the  lower  fragment  may  be  moved 
in  whatever  direction  the  foot  is  forced,  such  displace- 
ment being  resisted  and  limited  by  the  inferior  tibio- 
fibular  ligaments. 


Chap.  XXII.] 


THE  LEG. 


5°3 


In  rickets  the  tibia  is,  of  all  the  bones  of  the 
extremities,  the  one  that  most  frequently  becomes 
bent.  It  yields  at  its  weakest  part  (the  lower  third), 


Fig.  52. — Amputation  of  Leg  at  juuctioii  of  Upper  with  Middle  Third 
by  single  Posterior  Flap  (Agatz). 

a,  Tibia;  b,  fibula ;  c,  tibialisanticus:  d,  ext.  com.  digit;  «,  jteron.  loner. ;/.  lib. 
post. ;  g,  soleus  with  Hex.  long,  digit;  A,  gastrocnemius ;  <,  anterior  tibial 
vrscrls;  j,  post,  tibial  and  peroneal  vessels;  k,  int.  saphen.  vein;  l,  post, 
tibial  nerve. 

and  there  the  bone  will  be  found  to  have  developed  s. 
curve  forwards  and  a  little  outwards. 

Amputation  of  the  leg  at  the  junction  of  the 
upper  with  the  middle  third  by  unequal  antero- 
posteiior  flaps  may  be  taken  as  an  example.  In  the 


504  SURGICAL  APPLIED  ANATOMY.  [Chap. xxn. 

anterior  flap  the  following  structures  would  be  cut  : 
Skin,  cutaneous  nerves,  fascia,  tibialis  anticus,  extensor 
communis  digitorum,  and  a  little  of  the  extensor 
proprius  pollicis,  the  peroneous  longus,  and  a  small 
part  of  the  upper  extremity  of  the  peroneus  brevis, 


6. 


Fig.  53. — Transverse  Section  through  the  Lower  'I  hircl  of  the  Leg 
(Braune). 


the  anterior  tibial  vessels  and  nerve,  and  the  musculo- 
cutaneous  nerve.  In  the  posterior  flap  the  following 
would  be  the  parts  divided  :  Skin,  external  and 
internal  saphenous  veins  and  nerves,  fascia,  gastroc- 
nemius,  plantaris,  soleus,  tibialis  posticus,  flexor  longus 
digitorum,  a  little  of  the  upper  end  of  the  flexor 
longus  pollicis,  the  posterior  tibial  vessels  and  nerve, 
and  the  peroneal  vessels.  Fig.  52  shows  the  stump 
left  after  the  amputation  through  the  lower  part  of  the 
upper  third  of  the  leg,  by  means  of  a  single  flap  cut 
from  the  caif.  It  serves  to  show  the  relations  of  the 


chap,  xxui.j        THE  ANKLE  AXD  FOOT.  505 

chief  parts  divided,  and  gives  a  good  idea  of  the  stump 
that  would  be  left  in  an  amputation  by  an  anterior 
skin  flap  and  a  posterior  transfixion  flap  cut  from  tlie 
calf.  In  Fig.  53  is  shown  a  transverse  section  of  the 
leg  at  the  lower  third,  from  which  can  be  gathered  an 
idea  of  the  number  and  position  of  the  parts  cut  in 
amputations  through  that  part.  An  excellent  method 
of  amputation  at  the  upper  part  of  the  leg  is  by  a  single 
external  flap  containing  the  anterior  tibial  artery  in 
its  entire  length. 


CHAPTER  XXIII. 

THE     ANKLE     AND     FOOT. 

Surface  anatomy. — Bony  points. — The  outlines 
of  the  two  inalleoli  can  be  very  distinctly  defined. 
The  external  is  somewhat  the  less  prominent,  descends 
lower,  and  lies  farther  back  than  the  internal  process. 
The  tip  of  the  outer  malleolus  is  about  half  an  inch 
behind  and  below  the  tip  of  the  corresponding  bony 
prominence.  The  antero-posterior  diameter,  however, 
of  the  internal  malleolus  is  such  that  its  posterior 
border  is  on  a  level  with  that  of  the  outer  process 
behind. 

On  the  dorsum  of  the  foot  the  individual  tarsal 
bones  are  not  to  be  distinguished,  although  the 
astragalus  forms  a  distinct  projection  upon  that 
surface  when  the  foot  is  fully  extended. 

On  the  inner  side  of  the  foot  the  tuberosity  of  the 
os  calcis  may  be  felt  most  posteriorly.  In  front  of  it, 
and  about  one  inch  vertically  below  the  inner  malleo- 
lus, is  the  projection  of  the  sustentaculum  tali.  About 
one  and  a  quarter  inches  in  front  of  the  malleolus  the 
tubercle  of  the  scaphoid  can  be  distinctly  made  out. 


506  SURGICAL  APPLIED  ANATOMY.  [Chap.  xxm. 

In  the  interval  between  it  and  the  last-named  process 
lies  the  calcaneoscaphoid  ligament,  and  the  tendon  of 
the  tibialis  posticus.  Farther  towards  the  front  of 
the  foot  can  be  felt  the  ridge  formed  by  the  base  of 
the  first  metatarsal  bone,  and  between  it  and  the 
scaphoid  tubercle  lies  the  inner  cuneiform  bone.  Lastly, 
the  shaft  of  the  first  metatarsal  bone,  its  expanded 
head,  and  the  sesamoid  bones  that  lie  on  the  plantar 
aspect  of  the  metatarso-phalangeal  joint  can  be  more 
or  less  distinctly  defined.  On  the  outer  side  of  the 
foot  the  external  surface  of  the  os  calcis  is  subcutaneous 
in  nearly  the  whole  of  its  extent.  Less  than  an  inch 
below  and  in  front  of  the  malleolus  is  the  peroneal 
-tubercle,  with  the  short  peroneal  tendon  above  it  and 
the  long  one  below  it.  Some  two  and  a  half  inches 
from  the  outer  malleolus  the  projection  of  the  base  of 
the  fifth  metatarsal  bone  is  very  evident,  and  extending 
for  an  inch  or  so  behind  it  lies  the  cuboid  bone. 

Joint  lines. — The  ankle-joint  lies  about  on  the  level 
of  a  point  half  an  inch  above  the  tip  of  the  inner 
malleolus.  Immediately  behind  the  tubercle  of  the 
scaphoid  is  the  astragalo-scaphoid  articulation,  and  a 
line  drawn  transversely  across  the  dorsum  of  the  foot, 
just  behind  this  process,  very  fairly  corresponds  to  the 
mid-tarsal  joint  (the  joint  compounded  of  the  astragalo- 
scaphoid  and  calcaneo-cuboid  articulations). 

If  the  latter  articulation  be  approached  from  the 
outer  side  it  will  lie  opposite  a  point  midway  between 
the  outer  malleolus  and  the  prominent  base  of  the 
fifth  metatarsal  bone. 

The  lines  of  the  articulations  between  the  first 
and  fifth  rnetatarsal  bones  and  the  inner  cuneiform 
and  the  cuboid  respectively  are  easily  indicated,  being 
placed  just  behind  the  bases  of  the  former  bones. 
The  rnetatarso-phalaiigeal  articulations  are  situated 
about  one  inch  behind  the  webs  of  the  correspond- 
ing toes. 


chap,  xxin.]      THE  ANKLE  AND  FOOT.  507 

Tendons. — The  tondo  Achillis  stands  out  very 
conspicuously  at  the  back  of  the  ankle,  and  between  it 
and  the  malleoli  are  two  hollows  which  are  evident  in 
even  obese  individuals.  Over  the  front  of  the  ankle 
the  tendons  of  the  extensor  muscles  are  readily  to  be 
distinguished,  especially  when  the  joint  is  flexed. 
From  within  outwards  they  are  :  the  tendons  of  the 
tibialis  anticus,  extensor  longus  pollicis,  extensor 
longus  digitorum  and  peroneus  tertius.  Beneath  the 
tendons  of  the  extensor  of  the  toes,  and  on  the  outer 
part  of  the  dorsum  of  the  foot,  the  prominent  fleshy 
mass  formed  by  the  extensor  brevis  digitorum  can  be 
felt  and,  when  in  action,  seen.  Above  and  behind  the 
inner  malleolus  the  tendons  of  the  tibialis  posticus  and 
flexor  longus  digitorum  can  be  discerned,  the  former 
lying  nearer  to  the  bone.  Nearer  to  the  middle  line 
runs  the  flexor  longus  pollicis.  Behind  the  outer 
malleolus  the  long  and  short  peroneal  tendons  can  be 
felt,  lying  close  to  the  edge  of  the  fibula,  the  tendon  of 
the  smaller  muscle  being  the  closer  to  it. 

In  the  middle  of  the  sole  of  the  foot  the  resisting 
plantar  fascia  can  be  felt,  and  some  of  its  processes 
made  out  when  the  toes  are  drc,wn  up  by  the  extensors. 
The  fleshy  mass  on  the  inner  margin  of  the  foot  is 
formed  by  the  abductor  and  flexor  brevis  pollicis ;  that 
on  the  outer  side  by  the  abductor  and  flexor  brevis 
minimi  digiti. 

Vessels. — The  anterior  tibial  artery  and  nerve  are 
placed  opposite  the  ankle  joint,  between  the  tendons  of 
the  extensor  proprius  pollicis  and  longus  digitorum. 
The  dorsal  artery  runs  from  the  middle  of  the  ankle 
to  the  interval  between  the  bases  of  the  first  and 
second  metatarsal  bones.  It  may  be  felt  pulsating 
against  the  bones  along  the  outer  side  of  the  extensoi 
proprius  pollicis  tendon,  which  is  the  readiest  guide 
to  it.  The  plantar  arteries  start  from  a  point  midway 
between  the  tip  of  the  malleolus  interims  and  the 


508  SURGICAL  APPLIED 

centre  of  the  convexity  of  the  heel.  The  internal 
vessel  follows  a  line  drawn  fro-m  this  point  to  the 
middle  of  the  under  surface  of  the  great  toe.  The 
external  vessel  crosses  the  sole  obliquely  to  within  a 
thumb's  breadth  of  the  base  of  the  fifth  metatarsal 
bone.  From  thence  it  turns  more  transversely  across 
the  foot,  running  inwards  over  the  bases  of  the  meta- 
tarsal bones  to  inosculate  with  the  dorsalis  pedis  artei-y 
at  the  back  of  the  first  interosseous  space.  On  the 
dorsum  of  the  foot  the  subcutaneous  veins  may  be  seen 
forming  an  arch  convex  towards  the  toes,  and  from 
the  ends  of  the  arch  vessels  may  be  followed  into  the 
internal  and  external  saphenous  veins. 

The  ankle  and  foot. — The  skin  about  the 
ankle  and  over  the  dorsum  of  the  foot  is  thin  and  but 
loosely  attached  to  the  subjacent  parts.  It  becomes 
readily  excoriated,  as  is  often  the  case  where  splints 
or  instruments  have  been  improperly  applied.  Since  the 
skin  over  the  malleoli  lies  directly  upon  the  bone,  while 
that  covering  the  dorsum  of  the  foot  is  but  slightly 
separated  from  the  bones  of  the  tarsus,  it  follows  that 
the  integuments  in  this  region  are  readily  contused, 
and  may  suffer  gangrene  from  an  amount  of  pressure 
that  would  cause  but  little  trouble  in  other  parts. 
Over  the  sole  the  integument  is  dense  and  thick  in  all 
those  parts  that  come  in  contact  with  the  ground.  In 
the  normal  foot,  the  heel,  the  outer  margin  of  the  foot, 
and  the  line  of  metatarso-phalangeal  joints  are  in 
contact  with  the  ground  when  the  sole  is  placed  flat 
upon  it.  Along  the  inner  margin  of  the  foot  the 
integument  is  thin  and  fine.  The  skin  of  the  sole, 
like  that  of  the  palm  of  the  hand,  is  remarkably 
adherent  to  subjacent  parts.  When  cut  it  shows  no 
tendency  to  gape,  and  thus  exploratory  incisions  made 
into  the  part  (as  for  the  discovery  of  foreign  sub- 
stances) have  often  to  be  of  greater  dimensions  thau 
would  be  needed  elsewhere. 


chao.  xxni.]       TIIF.  ANKLE  AND  FOOT.  509 

The  subcutaneous  tissue  about  the  ankle  and  foot 
varies  greatly  both  in  quantity  and  character.  It  is 
abundant  and  well  provided  with  loose  fat  in  the 
immediate  neighbourhood  of  the  tendo  Achillis.  Over 
the  front  of  the  ankle  and  dorsum  of  the  foot  it  is 
very  lax  and  fairly  extensive,  although  possessing 
but  little  adipose  tissue  in  its  meshes.  In  the 
sole  the  subcutaneous  tissue  is  most  developed 
where  most  pressure  is  received.  Thus,  beneath 
the  heel  it  is  often  three-quarters  of  an  inch  ic 
thickness,  and  is  more  extensively  distributed  along 
the  outer  than  along  the  inner  margin  of  the  foot. 
It  is  here  composed  mainly  of  little  lobules  of  fat 
bound  down  and  enclosed  by  numerous  fibrous  bands 
that  pass  vertically  from  the  skin  to  the  deep  fascia. 
Over  the  centre  of  the  sole  it  is  more  scanty,  and 
the  union  between  the  integument  and  the  plantar 
fascia  is  more  direct.  It  very  closely  resembles  the 
subcutaneous  tissue  found  in  the  palm  and  upon 
the  scalp.  Beneath  the  heel  it  forms  an  actual  pad  or 
cushion  that  must  much  diminish  the  force  of  shocks 
transmitted  to  the  body  through  the  foot.  The  laxity 
of  the  tissue  upon  the  dorsum  of  the  foot  permits  of 
great  swelling  occurring  in  cases  of  diffuse  inflammation 
of  the  part,  and  in  conditions  producing  oedema.  In 
the  commencement  of  general  dropsy  the  dorsum  of 
the  foot  is  often  the  first  part  of  the  whole  body  to 
show  the  morbid  swelling.  In  the  sole,  on  the  other 
hand,  inflammatory  affections  and  effusions  of  various 
kinds  can  produce  but  little  external  change,  owing  to 
the  unyielding  character  of  the  parts  concerned. 
Collections  of  pus  upon  the  dorsum  may  form  readily 
and  extend  rapidly,  but  in  the  sole  of  the  foot  and 
in  the  heel  the  abscess  remains  small,  is  unable  to 
spread,  and  causes  intense  pain  by  reason  of  the  dense 
structure  of  the  tissues  involved. 

The  integuments  of  the  foot   are  well   supplied 


gio          SURGICAL  APPLIED  ANATOMY.  [Chap. xxm. 

with  nerves,  being  furnished  with  branches  from  no 
less  than  six  nerve  trunks,  the  rnusculo-cutaneous, 
the  anterior  tibial,  the  two  sapljenous,  and  the  external 
and  internal  plantar. 

Many  Pacinian  bodies  are  found  upon  these 
cutaneous  branches,  and  end-bulbs  are  met  with  in  the 
skin  on  the  sole  and  dorsum.  It  must  be  remembered 
that  these  nerves  come  from  a  considerable  distance 
(the  long  saphenous  from  the  lumbar  plexus,  and  the 
remainder  from  the  sacral)  so  that  pain  experienced 
in  the  foot  may  be  due  to  causes  very  remotely 
situated.  Thus,  Sir  B.  Brodie  mentions  a  case  of 
severe  neuralgia  of  the  foot,  after  each  evacuation  of  the 
bowels,  caused  by  the  descent  and  pressure  of  internal 
'  piles.  The  integuments  of  the  foot  respond  acutely 
to  sensations  of  pain,  of  pressure,  of  temperature,  and 
to  certain  unwonted  forms  of  tactile  impression,  such 
as  tickling.  Tactile  sensibility,  however,  as  measured 
by  the  sethesiometer,  is  not  acute,  the  dorsum  of  the 
foot  showing,  in  regard  to  this  matter,  no  more  sen- 
sitiveness than  does  the  skin  of  the  buttock. 

Over  the  "  tread  of  the  foot,"  and  especially  under 
the  ball  of  the  great  toe,  the  peculiar  affection  known 
as  "  perforating  ulcer  "  is  most  commonly  met  with. 
This  ulcer  occurs  as  an  occasional  symptom  in  certain 
nerve  maladies,  and  particularly  in  locomotor  ataxy. 

The  fasciae  of  the  foot  and  the  tendons 
about  the  ankle. — The  fascise  on  the  dorsum  occur 
in  two  layers,  a  superficial  one  that  is  continued  from 
the  anterior  annular  ligament,  and  a  deeper  placed 
over  the  extensor  brevis  and  interossei  muscles.  These 
membranes  are  both  thin  and  insignificant,  and  exercise 
no  influence  from  a  surgical  point  of  view.  The 
plantar  fascia  is  divided  into  three  parts,  a  central  or 
main  portion  which  is  extremely  dense  and  powerful, 
and  two  lateral  expansions  which  are  thin  and 
surgically  insignificant.  The  outer  of  the  two  lateral 


Chap.  XXITI.]      THE  ANKLE  AND  FOOT.  5  r  i 

portions  is,  however,  of  some  substance,  and  forms  a 
very  thick  band  between  the  os  calcis  and  fifth  meta- 
tarsal  bone,  that  may  become  rigidly  contracted  in 
some  forms  of  talipes.  The  central  expansion  assists 
greatly  in  supporting  the  antero-posterior  arch  of  the 
foot,  which  it  tends  to  maintain  in  the  manner  that 
the  bowstring  maintains  the  arch  of  the  bow. 

The  sinking  of  the  arch  that  occurs  in  "  flat  foot " 
is  associated  with  marked  yielding  of  this  fascia. 
The  plantar  fascia  is  often  found  much  contracted  (as 
a  rule,  secondarily)  in  certain  forms  of  club-foot, 
such  as  talipes  equinus  and  congenital  varus.  The 
term  "  talipes  cavus "  is  applied  to  a  deformity 
that  depends  mainly  or  entirely  upon  a  contraction 
of  the  plantar  fascia.  The  best  place  in  which  to 
divide  this  membrane  is  at  a  spot  about  one  inch  in 
front  of  its  attachment  to  the  os  calcis.  This  is  its 
narrowest  part,  and  the  knife  (which  should  be 
introduced  from  the  inner  side)  will  be  behind  the 
external  plantar  artery  which  runs  beneath  the  ex- 
pansion. An  abscess  situated  beneath  the  membrane 
will  be  very  closely  bound  down,  and  will  advance 
in  any  direction  other  than  through  the  membrane 
itself  so  as  to  point  in  the  centre  of  the  sole.  Such 
deep  collections  cause  intense  pain,  and  often  much 
destruction,  before  they  are  discharged.  They  may 
open  upon  the  dorsum,  or  may  extend  up  along  the 
tendons  to  the  region  of  the  ankle.  There  are  certain 
foramina  or  spaces  in  the  substance  of  this  layer 
occupied  usually  by  fat.  Through  one  or  more  of 
these  an  abscess  will,  in  exceptional  cases,  extend,  and 
then  spread  out  beneath  the  integuments.  Such  an 
abscess  will  have,  therefore,  two  cavities  united  by 
a  small  hole,  and  will  form  the  abcZs  en  bissac  or 
en  bouton  de  chemise  of  the  French.  The  plantar 
fascia  divides  into  slips  near  the  roots  of  the  toes,  and 
forms  a  series  of  arches,  beneath  which  pass  the 


512  SURGICAL  APPLIED  ANATOMY.  [Chap.  xxsu. 

tendons,  vessels,  and  nerves  bound  for  the  digits. 
Two  intermuscular  septa  connected  with  the  mem- 
brane separate  the  flexor  brevis  digitorum  from  the 
abductor  pollicis  on  the  one  side,  and  the  abductor 
minimi  digiti  on  the  other.  They  are,  however,  mem- 
branes of  too  feeble  a  structure  to  much  affect  the 
progress  of  a  deep  plantar  abscess. 

The  anterior  annular  ligament  is  divided  into  two 
parts ;  an  upper  band  in  front  of  the  tibia  and  fibula, 
and  a  lower  band  in  front  of  the  upper  limits  of  the 
tarsus.  Beneath  the  former  there  is  only  one  synovial 
sheath,  that  for  the  tibialis  anticus ;  beneath  the 
latter  are  three  sheaths  :  one  for  the  peroneus  tertius 
and  extensor  com  munis,  one  for  the  extensor  proprius 
"pollicis,  and  a  third  for  the  tibialis  anticus. 

According  to  Holden,  there  is  often  a  large 
irregular  bursa  between  the  tendons  of  the  extensor 
longus  digitorum  and  the  projecting  end  of  the 
astragalus.  This  bursa  sometimes  communicates  with 
the  joint  of  the  head  of  the  astragalus. 

Beneath  the  internal  annular  ligament  are  three 
synovial  sheaths  for  the  tendons  of  the  tibialis 
posticus,  flexor  longus  digitorum,  and  flexor  longus 
pollicis.  Inflammation  involving  the  sheath  for  the 
tibialis  posticus  may  spread  to  the  ankle  joint,  with 
which  the  tendon  is  in  close  relation.  Beneath  the 
outer  annular  ligament  is  the  single  synovial  sheath 
for  the  long  and  short  peroneal  tendons. 

In  severe  sprains  of  the  ankle  not  only  are  the 
ligaments  about  the  joint  more  or  less  ruptured,  but 
the  various  synovial  sheaths  just  named  are  apt  to  be 
torn.  The  long  abiding  trouble  in  the  part  that  often 
follows  severe  sprains  depends  to  a  great  extent  upon 
damage  to  these  sheaths,  and  to  extravasations  of 
blood,  and  subsequently  of  inflammatory  material, 
within  them. 

There  are  few  bursae  of  any  magnitude  about  the 


Chap,  xxiii.j      THE  ANKLE  AND  FOOT.  513 

foot,  save  one  between  the  tendo  Achillis  and  os  calcis, 
and  another  over  the  metatarso-phalangeal  joint  of 
the  great  toe.  The  first-named  bursa  rises  up  about 
half  an  inch  above  the  os  calcis,  and  bulges  out  on 
either  side  of  the  tendon.  When  inflamed  it  may 
produce  symptoms  like  those  of  ankle-joint  disease, 
and  when  suppurating  may  lead  to  caries  of  the 
os  calcis.  The  enlargement  of  the  bursa  over  the 
metatarso-phalangeal  joint  of  the  great  toe  consti- 
tutes a  bunion.  This  condition  is  generally  brought 
about  by  improperly-shaped  boots,  •which  force  the 
great  toe  outwards,  place  it  obliquely  to  the  long  axis 
of  the  foot  (with  which  it  should  be  parallel),  and 
render  the  metatarsal  joint  very  prominent.  The 
result  of  this  deformity  is  a  great  weakening  of  the 
toe  and  adjacent  part  of  the  foot,  a  lengthening  of 
the  internal  lateral  ligament  of  the  little  joint,  and 
a  displacement  outwards  of  the  tendon  of  the 
extensor  proprius  pollicis.  Bursae  are  often  de- 
veloped over  the  malleoli  in  tailors,  and  especially 
over  the  external  process,  the  part  most  pressed 
upon  when  sitting  cross  legged.  In  club-foot,  bursse 
are  found  over  any  points  that  are  exposed  to  undue 
pressure. 

The  tendons  about  the  ankle  are  not  infrequently 
ruptured  by  violence.  Those  that  most  frequently 
are  so  injured  are  the  tendo  Achillis,  and  the  tendons 
of  the  tibia! is  posticus  and  long  and  short  peroneal 
muscles.  The  tendo  Achillis  usually  breaks  at  a 
point  about  one  and  a  half  inches  above  its  insertion, 
where  it  becomes  narrowed  and  its  fibres  are  col- 
lected into  a  very  definite  bundle. 

In  some  forms  of  violence  the  synovial  and  fibrous 
sheaths  that  birid  down  a  tendon  may  be  ruptured 
and  it  be  allowed  to  become  displaced.  This  has  hap- 
pened to  the  tibialis  posticus  and  peroneal  muscles.  In 
each  instance  the  dislocated  structure  comes  forwards 

HH — 4 


514          SURGICAL  APPLIED  ANATOMY,  [Chap.  xxm. 

upon  or  in  front  of  the  malleolus.  No  tendon  in 
the  body  is  so  frequently  displaced  as  is  that  of  the 
peroneus  longus. 

The  tendons  about  the  ankle  are  frequently 
divided  by  operation.  The  tendo  Achillis  is  usually 
cut  about  one  inch  above  its  insertion,  the  knife 
being  entered  from  the  inner  side  to  avoid  the 
posterior  tibial  vessels.  The  tibialis  posticus  tendon 
is,  as  a  rule,  divided  just  above  the  base  of  the  inner 
malleolus.  There  is,  however,  enough  room  between 
the  annular  ligament  and  the  scaphoid  bone  to  cut 
it  on  the  side  of  the  foot.  The  anterior  tibial 
tendon  may  be  divided  readily  either  in  front  of  the 
^ankle  or  at  its  insertion  into  the  internal  cuneiform 
bona 

Blood-vessels. — The  lines  of  the  various  arteries 
have  been  already  indicated.  Wounds  of  the  plantar 
arch  are  serious,  on  account  of  the  depth  at  which  the 
external  plantar  artery  lies,  and  the  impossibility  of 
reaching  the  vessel  without  making  a  large  wound 
in  the  sole  that  would  open  up  important  districts 
of  connective  tissue,  and  do  damage  to  tendons 
and  nerves.  The  arch  is  formed  by  the  junction 
of  the  external  plantar  artery  with  the  dorsal 
artery  of  the  foot,  a  continuation  of  the  anterior 
tibial  vessel.  In  cases,  however,  of  bleeding  from 
the  arch  ligature  of  both  the  posterior  and  anterior 
tibial  vessels  at  or  just  above  the  ankle,  would  not 
necessarily  arrest  the  haemorrhage.  After  ligature 
of  these  vessels  blood  would  still  be  brought  in- 
directly to  the  arch  by  means  of  the  peroneal  artery. 
By  its  anterior  peroneal  branch  this  vessel  com- 
municates with  the  external  malleolar  branch  of  the 
anterior  tibial  artery,  and  with  the  tarsal  branch  of 
the  dorsalis  pedis.  By  its  terminal  branch  it  com- 
municates with  the  two  last-named  vessels,  and  also 
with  the  internal  calcaneal  branches  of  the  external 


Chap,  xxiii.)      THE  ANKLE  AND  FOOT.  515 

plantar  artery.  As  a  matter  of  practice,  however, 
elevation  of  the  limb,  together  with  pressure  upon  the 
wounded  point,  and  compression  of  the  main  artery, 
are  sufficient  to  check  most  haemorrhages  from  the 
plantar  arch. 

It  must  be  remembered  that  this  arch  can  be 
wounded  by  penetrating  wounds  inflicted  upon  the 
dorsum  of  the  foot ;  and  Dr.  Delorme  has  shown  how 
readily  various  parts  of  the  arch  may  be  ligatured  from 
the  dorsum  after  portions  of  one  or  other  of  the  meta- 
tarsal  bones  have  been  removed  Thus  by  resecting 
the  upper  part  of  the  shaft  of  the  fourth  metatarsal 
bone  in  one  case,  the  main  part  of  the  shaft  of  the 
third  bone  in  another,  and  the  upper  part  of  the 
shaft  of  the  second  bone  in  a  third  instance,  he  has 
been  enabled  to  expose  and  ligature  the  greater  part 
of  the  plantar  arch  from  the  dorsal  aspect  of  the 
foot. 

The  dorsalis  pedis  artery,  from  its  superficial 
position  and  its  close  contact  with  the  bones  of  the 
foot,  is  frequently  divided  in  wounds,  and  ruptured  in 
severe  contusions.  The  posterior  tibial  artery  at  the 
ankle  is  well  protected  by  the  projecting  malleolus, 
the  dense  annular  ligament,  and  the  tendons  that 
run  by  its  side. 

The  superficial  veins  of  the  foot,  like  those  of  the 
hand,  are  found  mainly  upon  the  dorsum  of  the 
member.  The  sole,  as  a  part  exposed  to  pressure,  is 
singularly  free  from  them.  About  the  malleoli,  and 
especially  about  the  inner  process,  these  veins  form  a 
considerable  plexus.  Hence  it  is  that  appliances  that 
fit  tightly  around  the  ankle  are  apt  to  produce 
oedema  and  pain  in  the  parts  beyond.  The  dull  pain 
in  the  feet  that  is  often  caused  by  tight  elastic-side 
boots  is  probably  due  to  the  same  cause.  It  will  be 
understood  that  wounds  and  suppurations  about  the 
dorsum  of  the  foot  are  more  apt  to  be  attended  by 


516          SURGICAL  APPLIED  ANATOMY.  [Chap.  xxni. 

phlebitis  than  are  like  lesions  when  situated  upon  the 
sole.  Venesection  is  sometimes  performed  in  the 
foot,  the  vein  opened  being  either  one  of  those  forming 
the  dorsal  plexus,  or  more  usually  the  internal 
saphenous  vein  just  above  the  malleolus.  The  vessels 
are  rendered  conspicuous  by  placing  the  foot  in  hot 
water,  and  then  applying  a  constricting  band  around 
the  leg. 

The  lymphatics  form  a  very  fine  and  elaborate 
plexus  in  the  coverings  of  the  sole,  from  which  vessels 
arise  that  reach  the  borders  and  dorsum  of  the  foot, 
and  principally  the  inner  border.  The  main  lymph 
vessels  of  the  part  are  found  upon  the  dorsum  and 
About  the  radicles  of  the  two  saphenous  veins.  Those 
on  the  inner  side  of  the  foot  are  by  far  the  more 
numerous;  they  follow  pretty  generally  the  course  of 
the  internal  saphenous  vein,  and  end  in  the  inguinal 
glands.  The  external  vessels  pass  up  along  the  outer 
ankle  and  outer  side  of  the  leg.  The  bulk  of  them 
pass  obliquely  across  the  ham  to  join  the  inner  set 
above  the  knee ;  others  reach  the  inner  set  by  crossing 
the  front  of  the  tibia,  while  a  few  follow  the  short 
saphenous  vein  and  end  in  the  popliteal  glands.  Thus, 
so  far  as  the  foot  is  concerned,  lymphangitis  is  more 
common  after  wounds  of  the  dorsum  than  after 
wounds  of  the  sole,  although  in  the  latter  locality  the 
frequent  retention  of  pus  beneath  the  dense  fascia 
greatly  favours  lymphatic  inflammations.  Since  many 
vessels  cross  the  shin  on  their  way  from  the  outer  to 
the  inner  set  of  vessels,  it  will  be  seen  that  abrasions, 
etc.,  of  that  part  of  the  limb  are  very  apt  to  be 
followed  by  inflammation  of  the  lymph  canals.  A 
lesion  on  the  inner  side  of  the  foot,  and  most  lesions 
on  the  dorsum,  will  be  associated  with  enlargement  of 
the  inguinal  glands ;  while  a  like  mischief  on  the 
outer  border  of  the  foot  may  attect  either  the  inguinal 
or  the  popliteal  chain  of  glands. 


Chap.  XXIII.]         THE   AffKLR    AND   FOOT.  517 

The  ankle-joint  is  a  very  powerful  articulation, 
its  strength  being  derived  not  only  from  the  shape  of 
its  component  bones,  but  also  from  the  unyielding 
ligaments  and  many  tendons  that  are  bound  about  it 
like  straps.  Of  the  ligaments,  the  two  lateral  are 
very  strong,  and  have  an  extensive  hold  upon  the 
foot.  The  anterior  and  posterior  are  extremely  thin 
and  insignificant,  although  the  latter  is  supported 
by  the  tendon  of  the  flexor  longus  pollicis,  which 
crosses  it.  When  effusion  takes  place  into  the  joint, 
it  first  shows  itself  in  front,  beneath  the  extensor 
tendons,  and  just  in  front  of  the  lateral  ligaments. 
This  is  due  to  the  feebleness  of  the  anterior  liga- 
ment and  the  extent  and  looseness  of  the  synovial 
sac  in  relation  with  that  structure.  More  extensive 
effusions  cause  a  bulging  behind  through  yielding 
of  the  thin  posterior  part  of  the  capsule,  and  fluctua- 
tion can  then  be  obtained  on  either  side  of  the  tendo 
Achillis.  In  no  ordinary  case  can  fluctuation  be 
detected  distinctly  beneath  the  unyielding  lateral 
ligaments.  Moreover,  the  loose  synovial  sac  of  the 
ankle-joint  extends  both  in  front  and  behind  beyond 
the  limits  of  the  articulation,  while,  at  the  sides,  it  is 
strictly  limited  to  the  joint  surfaces.  The  ankle  is  a 
perfect  hinge-joint,  and  permits  only  of  flexion  and 
extension.  The  very  slightest  amount  of  lateral 
movement  is  allowed  in  exti'eme  extension,  when  the 
narrower,  or  hinder,  part  of  the  astragalus  is  brought 
into  contact  with  the  widest,  or  anterior,  part  of  the 
tibio-fibular  arch.  When  obvious  lateral  movement 
exists  at  the  ankle,  the  joint  must  be  the  seat  of 
either  injury  or  disease,  and  it  is  important  not  to 
mistake  the  lateral  movements  permitted  between 
certain  of  the  tarsal  bones  for  movements  at  the 
ankle-joint.  Flexion  is  limited  by  the  posterior  and 
middle  parts  of  the  internal  ligament,  by  the  poste- 
rior part  of  the  external  ligament,  by  the  posterior 


518  SURGICAL  APPLIED  ANATOMY.  [Chap.  xxin. 

ligament,  and  by  the  contact  of  the  astragalus  with 
the  tibia.  Extension  is  limited  by  the  anterior  fibres 
of  the  inner  ligament,  the  anterior  and  middle  parts 
of  the  outer  ligament,  by  the  anterior  part  of  the 
capsule,  and  the  contact  of  the  astragalus  with  the 
tibia. 

Owing  to  its  exposed  position,  this  joint  is  very 
liable  to  become  inflamed  from  injury  or  other  ex- 
ternal causes.  When  inflamed,  no  distortion  is,  as  a 
rule,  produced,  the  foot  remaining  at  right  angles 
with  the  leg.  It  would  appear  that  this  position  is 
due  to  the  circumstance  that  the  flexor  and  extensor 
muscles  about  balance  one  another,  and  it  does  not 
seem  that  the  capacity  of  the  joint  is  affected  by 
the  posture  of  the  foot.  The  synovial  cavity  of  the 
ankle  is  in  communication  with  the  inferior  tibio- 
fibular  articulation. 

In  connection  with  the  subject  of  "  referred  pains," 
it  should  be  remembered  that  the  nerves  supplying 
the  ankls-joint  bring  that  articulation  into  relation 
with  two  great  plexuses,  with  the  lumbar  plexus 
through  the  internal  saphenous  nerve,  and  with  the 
sacral  plexus  through  the  external  division  of  the 
anterior  tibial  nerve. 

Dislocations  at  the  ankle-joint. — The  foot 
may  be  dislocated  at  the  ankle  in  five  directions, 
which,  placed  in  order  of  frequency,  are,  outwards, 
inwards,  backwards,  forwards,  and  upwards  between 
the  tibia  and  fibula.  These  dislocations  are  nearly 
always  associated  with  fracture  of  either  the  tibia  or 
fibula,  or  of  both  bones. 

1.  The  lateral  dislocations:  Outwards,  inwards. 
These  luxations  differ  somewhat  from  those  met  with 
in  other  joints.  In  the  great  majority  of  cases 
they  consist  of  a  lateral  twisting  of  the  foot,  of 
such  a  kind  that  the  astragalus  is  rotated  beneath  the 
tibio-fibular  arch.  There  is  no  great  removal  of  the 


Chap,  xxiii.]      THE  ANKLE  AND  FOOT.  519 

upper  surface  of  the  astragalus  from  that  of  the 
tibia,  but  rather  is  one  or  other  edge  of  the  former 
bone  brought  in  contact  with  the  horizontal  articular 
surface  of  the  latter.  Although  much  deformity  is 
produced,  the  actual  separation  of  the  foot  from  the 
leg  is  not  considerable.  In  some  rare  cases  a  true 
lateral  dislocation  in  the  horizontal  direction  has  been 
met  with. 

These  injuries  are  due  to  sudden  and  violent 
twistings  of  the  foot,  and  are  in  nearly  every  instance 
associated  with  fractures  of  the  tibia  or  fibula.  The 
luxation  outwards  is  due  to  forcible  eversion  of  the 
foot,  the  luxation  inwards  to  violent  inversion. 

It  is  of  interest,  in  the  first  place,  to  note  the  re- 
lation of  the  Jibula  to  injuries  at  the  ankle-joint, 
especially  as  a  fracture  of  the  lower  end  of  the 
shaft  of  that  bone  may  follow  alike  upon  both 
inversion  and  eversion  of  the  foot  The  lower  three 
or  four  inches  of  the  fibula  may  be  considered  to 
form  a  lever  of  the  first  kind  (Fig.  54,  A).  The  fulcrum 
is  at  the  inferior  tibio-fibular  articulation,  one  arm  of 
the  lever  is  the  malleolus  below  that  joint,  while  the 
other  arm  may  be  regarded  as  formed  by  the  lower 
two  or  three  inches  of  the  shaft  of  the  bone,  Now 
the  lower  ends  of  the  tibia  and  fibula  are  bound 
together  by  very  powerful  ligaments,  viz.,  the  anterior 
and  posterior  tibio-fibular,  the  transverse,  and  the 
inferior  interosseous.  I  would  venture  to  parti- 
cularly insist  that  in  no  ordinary  lesion  about  the 
ankle,  whether  fracture  or  dislocation,  do  these  liga- 
ments give  way.  If  they  should  yield,  then  an 
anomalous  form  of  fracture  or  luxation  will  be  pro- 
duced. In  forcible  eversion  of  the  foot,  the  internal 
lateral  ligament  becomes  stretched  and  tears,  the 
astragalus  is  rotated  laterally  beneath  the  tibio- 
fibular  arch  and  is  brought  into  violent  contact  with 
the  end,  qf  the  qu^er  malleolus.  This  process  is 


520 


SURGICAL  APPLIED  ANATOMY.  [Chap.  xxm. 


pushed  outwai'ds,  and  acts  as  one  end  of  a  lever.  The 
fulcrum  is  secured  by  the  unyielding  tibio-fibular 
ligaments,  and  the  fibula  breaks  at  the  other  end  of 
the  lever,  a  point  some  two  to  three  inches  above  the 


Fig.  54. — Diagrams  to  illustrate  the  Mechanism  involved  in  Fractures 
of  the  Lower  End  of  the  Fibula. 

A,  Parts  in  normal  position;  a,  tibio-flbular  ligaments;  b,  external  lateral  liga- 
ment ;  e,  internal  lateral  ligament ;  B,  fracture  of  fibula  due  to  evcrsion  of 
foot ;  c,  fracture  of  fibula  due  to  inversion  of  foot. 

end  of  the  bone  (Fig.  54,  B).  In  forcible  inversion  of 
the  foot,  the  astragalus  undergoes  a  little  lateral  rota- 
tion in  the  opposite  direction ;  the  external  lateral 
ligament  is  greatly  stretched,  and  tends  to  drag  the 
end  of  the  outer  malleolus  inwards.  If  the  liga- 
ment yields,  the  case  will  probably  end  as  a  sprained 
ankle,  or  pass  on  to  a  dislocation  inwards  of  the  foot. 
But,  if  it  remains  firm,  the  end  of  the  fibular  levef 


Chap,  xxni.]      THE  ANKLE  AND  FOOT.  521 

(the  tip  of  the  malleolus)  is  drawn  towards  the 
middle  line,  the  fulcrum  is  secured  by  the  tibio- 
fibular  ligaments,  and  the  shaft  breaks  at  the  other 
end  of  the  lever,  some  few  inches  above  the  end  of 
the  bone  (Fig.  54,  c).  It  will  be  seen  that  in  the 
fracture  due  to  eversion  the  upper  end  of  the  lower 
fragment  is  displaced  towards  the  tibia,  while,  in  the 
lesion  due  to  inversion,  it  is  displaced  from  that  bone. 
From  a  careful  examination  of  all  the  cases  of  frac- 
ture of  the  lower  end  of  the  fibula  admitted  into  the 
London  Hospital  during  the  time  I  held  the  post  of 
surgical  registrar  there,  I  convinced  myself  that  the 
lesion  is  much  more  frequently  due  to  eversion  than  to 
inversion  of  the  foot.  I  think  it  may  be  said  that  a 
fracture  of  the  lower  end  of  the  fibula  due  to  simple 
inversion  of  the  foot  is  not  possible  unless  the  ex- 
ternal lateral  ligament  remains  entire. 

In  the  outward  luxation,  better  known  as  Pott's  frac- 
ture, the  condition  is  such  as  has  just  been  described  in 
connection  with  the  effects  of  eversion  of  the  foot  upon 
the  fibula.  That  bone  is  always  broken  some  two  or 
three  inches  above  the  malleolus,  the  deltoid  ligament 
is  torn,  or  the  tip  of  the  inner  malleolus  wrenched  off. 
The  astragalus  is  so  rotated  laterally  that  the  foot  is 
much  everted,  its  outer  edge  is  raised,  while  its  inner 
edge  rests  upon  the  ground.  The  inferior  tibio- 
fibular  ligaments  remain  intact.  If  they  yield,  an 
unusual  form  of  fracture  or  dislocation  is  produced, 
as  already  stated.  Boyer  relates  a  case,  considered 
to  be  unique,  where  the  foot  was  luxated  outwards, 
but  without  any  fracture  of  the  fibula.  That  bone, 
however,  had  been  forced  upwards  entire,  and  its 
head  dislocated  from  the  articular  facet  of  the  tibia. 
A  horizontal  dislocation  outwards,  without  rotation  of 
the  foot  and  without  fracture  of  the  fibula,  is  possible 
if  the  inferior  tibio-fibular  ligaments  are  entirely  torn. 

In  Dupuytren's  fracture  (a  rare  injury)  the  fibula 


522          SURGICAL  APPLIED  ANATOMY.  [Chap. XXIIL 

is  fractured  from  one  to  three  inches  above  the 
malleolus,  the  inferior  tibio  -  fibular  ligaments  are 
entirely  lacerated,  or  the  portion  of  the  tibia  to 
which  they  are  attached  is  torn  away,  and  remains 
connected  with  the  lower  fragment  of  the  fibula. 
The  foot  is  dislocated  horizontally  outwards,  and  is 
drawn  upwards,  the  extent  of  the  upward  displace- 
ment depending  upon  the  height  at  which  the  fibula 
breaks. 

In  the  inward  luxation  the  external  lateral  liga- 
ment is  torn  or  the  tip  of  the  outer  malleolus  dragged 
away,  the  deltoid  ligament  is  intact,  but  the  internal 
malleolus  is  commonly  broken  by  the  violence  with 
.which  the  astragalus  is  brought  into  contact  with  it. 
That  bone  itself  may  be  broken,  and  is  in  any  case 
rotated  laterally,  so  that  the  foot  is  inverted,  and  its 
inner  border  much  raised.  In  all  forms  of  this  dis- 
location, whether  simple  or  complicated,  the  inferior 
tibio-fibular  ligament  remains  intact. 

2.  The  antero-posterior  dislocations — Backwards  ; 
forwards.  These  injuries  are  brought  about  by  great 
force  applied  to  the  foot  while  the  leg  is  fixed,  or 
more  commonly  by  sudden  arrest  of  the  foot  during 
some  violent  impulse  given  to  the  body,  as  on  jumping 
from  a  carriage  when  in  motion.  In  the  luxation 
backwards  the  astragalus  is  displaced  behind  the  tibia, 
while  the  articular  surface  of  the  latter  bone  rests 
upon  the  scaphoid  and  cuneiform  bones.  The  anterior 
and  posterior  ligaments  are  entirely  torn,  and  a  great 
part  also  of  the  two  lateral  bands.  The  fibula  is 
broken  some  two  or  three  inches  above  the  malleolus, 
and  there  is  usually  a  fracture  also  of  the  inner 
malleolus. 

The  luxation  forv/ards  is  of  extreme  rarity.  In 
the  few  reported  cases  one  or  both  malleoli  wero 
broken.  II.  W.  Smith  believes  that  the  dislocation  is 
never  complete. 


Chap,  xxiii.]      THE  ANKLE  AND  FOOT. 


523 


3.  The  dislocation  upwards. — In  this  rare  accident 
the  inferior  tibio-fibular  ligaments  are  ruptured,  the 
two  bones  are  widely  separated  at  their  lower  ends, 
and  the  astragalus  is  driven  up  between  them.  The 
anterior  and  posterior  ligaments  are  entirely  rup- 
tured, but  the  lateral  ligaments  usually  escape  with 
but  some  slight  laceration.  The  accident  appears  to 
be  generally  caused  by  a  fall,  the  patient  alighting  flat 
upon  the  soles  of  the  feet.  Mr.  Bryant  records  a  case 
in  which  both  feet  were  similarly  dislocated  upwards. 

The  foot. — There  are  two  arches  in  the  foot,  an 
antero-posterior  and  a  transverse. 

1.  The  antero-posterior  arch  has  its  summit  at  the 
astragalus.  It  may  be  considered  as  composed  of 


Fig.  55.— Antero- Posterior  Section  of  the  Foot  (Rttdinger). 

1,  Tibia ;  2,  astrarolua  :  3,  os  calcis ;  4,  scaphoid  :  5.  int.  cuneiform  ;  6,  flrst 
niftatarsal  bone ;  7  and  8,  pliulangee  of  great  toe. 

two  piers.  The  hinder  pier  consists  of  the  os  calcis, 
the  anterior  pier  of  the  scaphoid,  cuneiform  and 
metatarsal  bones.  The  astragalus  forms  the  keystone 
of  the  arch,  the  head  of  the  bone  especially  perform- 
ing that  function  (Fig.  55). 


524  SURGICAL  APPLIED  ANATOMY.  [Chap.  xxm. 

The  foot  rests  upon  the  heel,  the  heads  of  the 
metatavsal  bones,  and  the  outer  margin  of  the  foot 
The  hinder  pier  is  solid,  is  made  up  of  a  strong 
bone,  and  contains  only  one  joint.  It  serves  to 
support  the  main  part  of  the  weight  of  the  body,  and 
gives  a  firm  basis  of  attachment  to  the  muscles  of  the 
calf.  The  anterior  part  of  the  arch,  oil  the  other 
hand,  contains  many  small  bones  and  a  number  of 
complicated  joints.  It  serves  to  give  elasticity  to  the 
foot,  and  to  diminish  the  effect  of  shocks  received 
upon  the  sole  of  the  foot.  The  comparative  value  of 
the  two  piers  of  the  arch  in  this  latter  respect  can  be 
estimated  by  jumping  from  a  height  and  alighting 
first  upon  the  heels  and  then  upon  the  balls  of  the 
toes.  The  inner  part  of  the  arch  is  much  more 
curved  than  the  outer,  and  forms  the  instep. 

2.  The  transverse  arch  is  most  marked  across  the 
cuneiform  bones.  It  gives  much  elasticity  to  the  foot 
and  affords  protection  to  the  vessels  of  the  sole. 

These  two  arches  result  from  the  shape  of  the 
component  bones,  and  are  maintained  by  the  various 
ligaments.  The  peroneus  longus  tendon,  and  nearly 
all  the  ligaments  which  connect  the  first  and  second 
rows  of  tarsal  bones  on  both  the  plantar  and  dorsal 
aspects,  are  inclined  forwards  and  inwards,  and  by  this 
arrangement  are  well  adapted  to  maintain  the  integrity 
of  the  transverse  as  well  as  of  the  antero-posterior 
arch. 

The  chief  joints  of  the  foot.  —  The  articu- 
lation between  the  os  calcis  and  astragalus  forms 
a  double  joint.  The  posterior  joint,  that  behind  the 
interosseous  ligament,  has  a  separate  synovial  sac, 
while  the  anterior  communicates  with  the  synovial 
cavity  of  the  mid-tarsal  articulation.  The  two  bones 
are  held  together  not  only  by  the  interosseous,  the 
internal,  external,  and  posterior  calcaneo-astragaloid 
ligaments,  but  are  supported  also  by  the  external 


Chap,  xxiii.)      THE  ANKLE  AND  FOOT.  525 

calcaneo-scaphoid  ligament,  the  two  lateral  ligaments 
of  the  ankle,  and  the  tendons  about  the  part.  The 
articulation  permits  of  adduction  and  abduction,  and  of 
some  rotation  of  the  foot  beneath  the  astragalus.  Adduc- 
tion is  associated  with  some  turning  of  the  toes  inwards, 
and  abduction  with  some  turning  of  them  outwards. 

Dislocations  of  the  astragalus.— This  bone 
is  sometimes  luxated  alone,  being  separated  from  its 
connections  with  the  os  calcis,  the  tibia,  the  fibula, 
and  the  scaphoid  bone.  The  displacement  may  be 
either  forwards,  backwards,  or  laterally.  The  lateral 
luxations  are  nearly  always  oblique,  the  bone  passing 
as  a  rule  forwards  as  well  as  inwards  or  outwards. 
The  luxation  forwards  is  by  far  the  most  common 
lesion,  the  next  in  frequency  being  a  luxation  out- 
wards and  forwards.  The  backward  displacement  is 
extremely  rare.  The  dislocations  are  usually  com- 
plete, are  very  often  compound,  especially  when  in 
the  lateral  direction,  and  are  commonly  associated 
with  fracture  of  the  tibia  or  fibula,  or  of  the  astragalus 
itself.  A  lateral  complete  dislocation  is  impossible 
without  fracture  of  one  or  other  malleolus.  In  these 
injuries  the  interosseous  ligament  between  the  os  calcis 
and  astragalus  is  entirely  torn,  as  are  also  a  greater 
part  of  the  lateral  ligaments  of  the  ankle,  and  the 
various  bands  that  connect  the  astragalus  with  the  os 
calcis  and  scaphoid.  In  all  instances  the  malleoli  are 
brought  nearer  to  the  sole.  In  the  antero-posterior 
luxations  the  foot  as  a  rule  undergoes  no  rotation, 
but  in  the  luxation  of  the  bone  forwards  and  outwards 
it  becomes  inverted,  and  in  the  displacement  forwards 
and  inwards  everted. 

Dislocation  of  the  os  calcis. — This  bone, 
although  often  fractured,  is  very  rarely  luxated. 
When  displaced,  however,  it  is  usually  displaced  out- 
wards, and  is  torn  away  from  its  attachments  to  the 
astragalus  and  cuboid,  or  from  the  former  bone  alone. 


526  SURGICAL  A /'PLIED  ANATOMY.  [Chap.  xxm. 

Subastragaloid  dislocations  of  the  foot. 

— In  these  lesions,  which  are  not  very  uncommon,  the 
astragalus  remains  in  position  between  the  tibia  and 
fibula,  while  the  rest  of  the  foot  is  dislocated  below 
that  bone.  The  luxation,  therefore,  concerns  the 
calcaneo-astragaloid  and  astragalo -scaphoid  joints. 
The  foot  may  be  displaced  either  forwards,  backwards, 
or  laterally.  The  forward  dislocation  is  extremely 
rare,  and  the  lateral  luxations  are  nearly  always 
oblique.  In  the  most  usual  displacement  the  foot  is 
dislocated  outwards  or  inwards,  and  is  at  the  same 
time  carried  backwards.  These  luxations  are  often 
compound,  especially  when  lateral.  They  are,  as  a  rule, 
incomplete  as  regards  the  calcaneo-astragaloid  joint, 
while,  on  the  other  hand,  the  displacement  of  the  astra- 
galus from  the  scaphoid  is  in  nearly  every  instance  com- 
plete. In  all  cases  the  interosseous  ligament  between 
the  os  calcis  and  astragalus  must  be  torn,  and  there  will 
also  be  more  or  less  laceration  of  the  astragalo-scaphoid 
ligament,  and  of  one  or  both  of  the  lateral  bands  of  the 
ankle  joint.  The  malleoli  are  very  often  fractured. 

It  is  only  necessary  to  notice  in  any  detail  the  two 
lateral  luxations,  as  being  the  only  common  forms.  In 
the  inward  dislocation  the  foot  is  inverted,  its  inner 
border  is  raised,  is  shortened,  and  rendered  concave, 
while  its  outer  border  is  lengthened  and  made  convex. 
The  deformity  much  resembles  that  of  talipes  varus. 
The  head  of  the  astragalus  with  the  outer  malleolus 
form  a  projection  at  the  outer  aspect  of  the  foot,  while 
below  them  a  deep  hollow  exists.  The  inner  border  of  the 
os  calcis  is  very  prominent  at  the  internal  side  of  the 
limb,  while  the  inner  malleolus  is  buried  in  the  hollow 
left  by  the  displacement  of  that  bone.  The  calcaneum 
and  scaphoid  are  approximated.  In  the  outward 
luxation  the  foot  is  abducted,  its  outer  border  is  raised, 
and  the  deformity  produced  is  not  unlike  that  of  talipes 
valgus.  The  outer  malleolus  is  lost  in  the  hollow 


Chap,  xxn i.]      THE  ANKLE  AND  FOOT.  527 

caused  by  the  eversion  of  the  foot,  while  the  tibial 
malleolus  and  head  of  the  astragalus  form  a  projection 
on  the  inner  aspect  of  the  limb. 

The  medio-tarsal  joint  is  composed  of  two 
articulations,  the  astragalo-scaphoid  and  calcaneo- 
cuboid.  The  ligaments  supporting  the  former  joint 
are  the  external  and  inferior  calcaneo-scaphoid  and 
the  astragalo-scaphoid ;  while  the  latter  articulation 
is  maintained  by  the  internal  and  dorsal  calcaneo- 
cuboid  ligaments,  and  the  long  and  short  plantar. 
Movement  is  somewhat  freer  in  the  astragaloid  than 
in  the  calcaneal  segment  of  the  joint.  The  movements 
permitted  in  the  articulation  as  a  whole  consist  of 
flexion  and  extension,  with  some  rotation  around  an 
antero-posterior  axis  whereby  the  sole  can  be  turned 
in  or  out.  Flexion  is  associated  with  inward  rotation 
of  the  sole  and  adduction  of  the  toes,  extension  with 
outward  rotation  of  the  sole  and  abduction  of  the  toes. 
It  should  be  noted  that  the  movements  of  turning  the 
toes  either  in  or  out  take  place  mainly  at  the  hip- 
joint  ;  while  the  turning  of  one  edge  of  the  foot  either 
up  or  down  is  a  movement  that  mostly  concerns  the 
medio-tarsal  and  calcaneo-astragaloid  joints.  The 
chief  deformities  in  club-foot  take  place  about  the 
former  articulation. 

Club-foot. — It  is  usual  to  divide  the  various 
forms  of  talipes,  or  club-foot,  into  four  main  divisions, 
viz.  (1)  T.  equinus;  (2)  T.  calcaneus ;  (3)  T.  varus; 
and  (4)  T.  valgus.  Four  secondary  forms  result  from 
combinations  of  these  principal  varieties,  viz.  T. 
equino-varus,  T.  equino-valgus,  T.  calcaneo- varus,  and 
T.  calcaneo-valgus. 

1.  Talipes  equinus.  In  this  deformity  the  heel  is 
drawn  up,  and  the  patient  walks  upon  the  balls  of  the 
toes.  The  contracting  muscles  are  those  of  the  calf 
attached  to  the  tendo  Achillis.  In  a  well-marked  case 
the  os  calcis  is  much  raised,  and  may  even  be  brought 


528  SURGICAL  APPLIED  ANATOMY,  tchap.  xxm. 

in  contact  with  the  tibia.  The  astragalus  is  displaced 
downwards,  and  projects  upon  the  dorsum.  The  foot 
tends  to  become  more  and  more  bent  at  the  medio- 
tarsal  joint,  until  at  last  the  scaphoid  may  even  touch 
the  os  calcis.  The  ligaments  of  the  sole  are  usually 
inuch  contracted. 

2.  Talipes  calcaneus.     In  this  form   of  club-foot 
the  toes  are  drawn  up,  and  the  patient  walks  upon  the 
heel.      The  contracting  muscles  are  the  extensors  on 
the  anterior  aspect  of    the  limb.       The  os  calcis    is 
rendered  more  vertical,  and  the  astragalus  becomes  so 
obliquely  placed  that  part  of  its  upper  articular  surface 
may  project  beyond  the  tibia  in  a  backward  direction. 

3.  Talipes  varus.      This  is  the  commonest  form. 
In  a  well-marked    congenital    case   there    is    a  four- 
fold   deformity  :    (1)  The  heel    is    drawn  up  by  the 
muscles    attached    to    the   tendo    Achillis ;    (2)    the 
foot  is  adducted  ;    and   (3)   its  inner  edge  is  drawn 
upwards  by  the  contraction  of  the  tibialis  anticus  and 
posticus ;    (4)  the    sole    is    contracted   by  the  flexor 
longus    digitorum  muscle  and  the  shrinking  of    the 
plantar    fascia    and    ligaments.     In    this    variety  of 
talipes  the    os    calcis  is  drawn  into  a  more  vertical 
position.      The  astragalus  is  displaced  forwards  and 
downwards,  so  that  some  part  of  its  upper  articular 
surface    becomes    superficial    on    the    dorsum.     The 
scaphoid  is  displaced  upwards  and  backwards,  until 
its  inner  border  often  touches  the  internal  malleolus. 
The  three  cuneiform  bones  follow  the  scaphoid,  and 
the  cuboid  becomes  the  lowest  bone  in  the  tarsus. 

4.  In  talipes  valgus  the  foot  is  abducted  and  its 
outer  border  drawn  upwards.     The  contracting  muscles 
are  the  two  peronei.     In  a  well-marked  congenital 
case  the   os  calcis  is  found  a  little  raised  and    the 
astragalus  is  displaced  forwards  and  downwards.     The 
scaphoid  is  so  rotated  that  its  inner  pai-t  is  depressed 
and  its   outer  raised.     The  internal  portion  of    the 


Chap,  xxiii.]      THE  ANKLE  AND  FOOT.  529 

bone  forms  one  of  the  two  projections  obvious  on  the 
inner  side  of  the  foot,  the  other  prominence  being 
formed  by  the  head  of  the  astragalus.  The  cuboid 
is  found  to  be  a  little  rotated  outwards.  The  arch  of 
the  foot  is  lost,  and  all  those  ligaments  are  stretched 
that  serve  to  support  and  maintain  that  arch. 

Of  the  mixed,  or  secondary,  forms  of  talipes 
nothing  need  be  said.  They  are  the  results  merely  of 
a  combination  of  the  primary  varieties. 

As  trouble  is  often  caused  in  talipes  by  pressure 
being  brought  to  bear  upon  an  unusual  part  of  the 
foot,  it  is  well  to  note  upon  what  portion  of  the 
member  the  patient  treads  in  the  different  varieties  of 
the  deformity.  In  varus  the  "  tread  "  is  mainly  upon 
the  outer  side  of  the  fifth  metatarsal  bone ;  in  valgus 
upon  the  internal  malleolus  and  scaphoid  ;  in  equinus 
upon  the  bases  of  all  the  toes  ;  in  equino- varus  upon 
the  base  of  the  little  toe ;  in  equino-valgus  upon  the 
base  of  the  great  toe ;  in  all  forms  of  calcaneus  upon 
the  heel.  In  cases  of  extreme  and  obstinate  club- 
foot  wedges  of  bone  are  sometimes  removed  by  the 
operation  known  as  T'arsectomy.  Thus  in  talipes 
equino-varus  the  base  of  the  wedge  will  be  on  the 
outer  side  of  the  foot  and  will  be  mainly  represented 
by  the  cuboid  ;  the  apex  will  be  at  the  scaphoid. 

Flat-foot,  or  splay-foot,  are  the  names  given 
to  a  deformity  due  probably  to  the  yielding  of  certain 
ligaments,  whereby  the  arch  of  the  foot  is  lost  and 
the  sole  becomes  more  or  less  perfectly  flat.  The 
foot,  at  the  same  time,  is  abducted,  and  the  outer 
border  is  often  a  little  raised,  so  that  the  patient 
walks  mainly  upon  the  inner  side  of  the  foot.  This 
deformity  is  met  with  in  those  who  stand  a  great 
deal,  and  is  the  direct  result  of  yielding  of  the  tarsal 
ligaments  from  long-continued  pressure.  When  the 
weight  of  the  body  is  brought  to  bear  on  the  foot 
placed  flat  upon  the  ground,  it  will  be  transmitted  in 
ii— 4 


530           SURGICAL  APPLIED  ANATOMY.  [Chap.  xxm. 

an  oblique  direction  from  above  downwards  and  in- 
wards. The  foot  therefore  tends  to  become  abducted, 
a  tendency  resisted  by  such  powerful  ligaments  as  the 
internal  lateral  of  the  ankle  and  those  connecting  the 
os  calcis  with  the  astragalus.  In  flat-foot,  these  liga- 
ments yield,  and  the  toes  consequently  are  turned  out 
or  abducted.  The  ligament,  however,  that  is  mainly 
affected  in  this  deformity  is  the  inferior  calcaneo- 
scaphoid.  This  strong  band  of  fibres  supports  the 
head  of  the  astragalus  and  holds  up  the  very  key- 
stone of  the  plantar  arch.  When  it  yields,  the  head 
of  the  astragalus  is  pressed  forwards,  downwards, 
and  inwards  by  the  superincumbent  weight,  and  the 
foot  beyond  becomes,  as  a  consequence,  over-extended 
and  turned  out.  The  os  calcis  slants  inwards  and  its 
anterior  end  is  depressed.  The  sustentaculum  tali, 
the  head  of  the  astragalus,  and  the  scaphoid  tubercle 
form  prominences  on  the  inner  side  of  the  foot.  The 
long  and  short  plantar  ligaments  also,  which  contri- 
bute so  much  to  the  maintenance  of  the  arch  of  the 
foot,  in  time  yield,  and  allow  of  a  still  greater 
degree  of  deformity.  There  is  a  stretching  also 
of  the  deltoid  ligament.  In  neglected  cases  the 
distortion  is  rendered  more  or  less  permanent  by 
alterations  in  the  shape  of  the  tarsal  bones,  and  by  a 
contraction  of  such  ligaments  as  have  been  relaxed  by 
the  deformity.  The  foot  being  abducted,  and  its 
outer  border  a  little  raised,  the  peronei  muscles  be- 
come relaxed,  shorten,  and  contribute  to  the  per- 
manency of  the  disorder.  It  will  be  understood  that 
the  abnormal  pressure  brought  to  bear  upon  the 
various  tarsal  bones  and  articulations  will  cause  severe 
pain  to  be  often  associated  with  this  affection. 

It  may  be  noted  that  the  medio-tarsal  joint,  which 
is  so  conspicuously  involved  in  the  distortion,  is 
supplied  by  the  anterior  tibial,  inusculo-cutaneous, 
and  external  plantar  nerves. 


chap,  xxiii.]      THE  ANKLE  AND  FOOT. 


531 


The  tarsal  bones,  owing  to  their  spongy 
character,  are  readily  broken  by  direct  violence,  as  in 
severe  crushes.  The  soft  parts  that  cover  these  bones 
being  scanty  upon  the  dor- 
sal aspect  of  the  foot,  it 
follows  that  these  accidents 
are  often  compound  and 
associated  with  much  lacer- 
ation of  the  integuments. 

The  tarsal  bone  the 
most  frequently  fractured 
is  the  os  calcis.  This  bone 
may  be  broken  by  a  fall 
upon  the  heel,  and  in  many 
instances  has  been  the  only 
one  fractured  by  such  an 
accident.  A  few  cases  have 
been  recorded  of  fracture 
of  the  calcaneum  by  mus- 
cular violence,  the  muscles 
producing  the  lesion  being 
those  attached  to  the  tendo 
Achillis.  Thus,  Sir  A. 
Cooper  reports  the  case  of 
a  woman,  aged  forty-two, 
in  whom  a  large  fragment 
of  the  posterior  part  of  the 
os  calcis  was  torn,  away 
by  the  muscles  and  drawn 
some  two  and  a  half  inches 
away  from  the  heel.  The 
accident  was  caused  by  her 
taking  a  false  step.  Abel 
has  collected  three  cases 
of  fracture  of  the  sustenta- 
culum  tali.  He  believes 
that  this  injury  may  be 


Fig.  56.— Oblique  Antero-Posterior 
Section  of  the  Foot  (Eiidiuger). 


1,  Tibia  ;  2,  fllmla ;  3.  astragalus 
external  lateral  li 


ciilcis;  5,  external  lateral  ligament: 
6,  internal  lateral  lijrament :  7,  inter- 
OMMMI*  ligament  lietweenMtnntu 

and  os  calcis :  8,  head  of  astragalus  ; 
it.  scaphoid;  10,  11,  and  12,  the  three 
cuneiform  bones ;  13,  cuboid. 


532          SURGICAL  APPLIED  ANATOMY.  [Chap.  xxui. 

produced  by  falls  upon  the  sole  or  by  extreme  supi- 
nation  (rotation  outwards)  of  the  foot,  whereby  the 
astragalus  is  forced  violently  against  the  process. 

The  astragalus  alone  may  be  broken  by  a  fall  upon 
the  feet,  and  such  accidents  are  often  associated  with 
fractures  of  both  that  bone  and  the  os  calcis.  It 
must  be  noted,  however,  that  in  a  fall,  when  the 
patient  alights  upon  the  feet,  the  tibia  and  fibula  are 
much  more  likely  to  be  broken  than  are  the  tarsal 
bones,  since  the  bones  of  the  leg  transmit  the  weight 
of  the  body  directly,  whereas  that  weight  is  much 
diffused,  and  broken-up  when  passing  through  the  foot 
with  its  many  bones  and  joints. 

The  metatarsal  bones  and  phalanges  are  nearly 
always  broken  by  direct  violence.  I  had,  however, 
under  my  care  at  the  London  Hospital  a  man  who 
had  broken  the  shafts  of  the  three  outer  metatarsal 
bones  by  simply  slipping  off  the  edge  of  the  curb. 

With  regard  to  the  luxations  of  the  foot  not  yet 
considered,  it  may  be  said  that  the  cuboid  is  never 
dislocated  only.  Walker  reports  a  case  of  dislocation  of 
the  scaphoid  alone,  that  structure  being  quite  separated 
from  the  astragalus  and  cuneiform  bones.  The  acci- 
dent was  brought  about  by  alighting  upon  the  ball  of 
the  foot  when  jumping,  and  the  little  bone  was  found 
projecting  on  the  dorsum.  Mr.  Bryant  has  mentioned 
an  instance  of  dislocation  of  the  scaphoid  inwards. 
As  a  rule,  however,  this  bone  when  displaced  is 
dislocated  along  with  the  astragalus. 

Of  the  cuneiform  bones  the  one  most  often  lux- 
ated alone  is  the  internal.  The  attachment  of  the 
tendons  of  the  tibialis  anticus  and  peroneus  longus 
about  the  internal  cuneiform  and  first  metatarsal 
bones  renders  it  common  for  the  latter  to  follow 
its  tarsal  colleague  when  dislocated.  Mr.  Luke 
has  recorded  a  case  of  incomplete  luxation  of 
all  three  cuneiform  bones  upwards,  and  at  least 


Chap,  xxiii.]      THE  ANKLE  AND  Poor.  533 

three  cases  have  been  described  of  dislocation  cf  the 
internal  bone  upwards  and  backwards,  together  with 
a  like  displacement  of  all  the  metatarsals. 

One  or  more  of  the  metatarsat  bones  may  be 
luxated,  or  the  entire  series  may  be  displaced  upwards, 
downwards,  inwards,  or  outwards,  the  first-named 
lesion  being  the  most  common.  In  rarer  instances, 
one  bone  has  been  thrown  in  one  direction  and  its 
fellow  or  fellows  in  another. 

Dislocation  of  the  first  phalanx  of  the  great  toe 
is  often  very  difficult  to  reduce,  as  is  also  the  case  in 
the  corresponding  luxation  in  the  thumb.  When  the 
displacement  is  dorsal,  the  difficulty  is  probably  due 
to  the  sesamoid  bones,  which  in  this  joint  take  the 
place  of  the  glenoid  ligament  or  fibro-cartilaginous 
plate  of  the  other  toes.  "  Like  the  glenoid  ligaments, 
the  sesamoid  bones  are  much  more  firmly  connected 
with  the  phalanx  than  with  the  metatarsal  bone,  and 
thus  get  torn  away  and  shut  back  behind  the  head  of 
the  metatarsal  bone  ;  or  it  may  be  that  the  sesamoid 
bones,  retaining  their  connections  with  the  lateral 
ligaments  of  the  joint  as  well  as  with  the  short  flexor 
tendons,  are  separated  from  one  another,  and  so  allow 
the  head  of  the  metatarsal  bone  to  pass  forwards,  and 
thus  become  nipped,  as  it  were,  in  a  button-hole 
between  them  "  (Henry  Morris). 

There  are  six  synovial  cavities  in  the  foot, 
excluding  that  of  the  ankle-joint,  viz.,  one  for  the 
posterior  calcaneo-astragaloid  joint,  a  second  for  the 
anterior  calcaneo-astragaloid  and  astragalo-scaphoid 
joints,  a  third  between  the  os  calcis  and  cuboid,  a 
fourth  between  the  latter  bone  and  the  two  outer 
metatarsals,  a  fifth  for  the  joint  between  the  inner 
cuneiform  and  first  metatarsal  bones,  and  a  sixth  for 
the  remaining  articulations  (Fig.  56).  These  synovial 
cavities  tend  greatly  to  diffuse  disease  among  the 
various  bones  of  the  foot  when  once  one  bone  has 


534 


SURGICAL  APPLIED  ANATOMY.  [Chap.  xxin. 


f- 


become   inflamed.      The  best  position,   therefore,  for 
bone  disease,  with  reference  to  the  question  of  exten- 
sion,  would    be    in    the   hinder    parts   of    either  the 
,.,  os  calcis  or  astragalus, 

and  one  of  the  worst 
positions  would  be  as- 
sumed by  disease  in- 
volving the  scaphoid 
bone. 

Symc's  ampu- 
tation at  the  ankle. 
— In  the  heel-flap  are 
cut  the  integuments, 
the  external  saphenous 
nerve  and  vein,  the 
peroneus  longus,  pero- 
neus  brevis,  tibialis 
posticus,  flexor  longus 
digitorum,flexorlongus 
pollicis,tendo  Achillis, 
points  of  origin  of  the 
flexor  brevis  digitorum 
and  of  the  two  ab- 
ductor muscles  and 
the  internal  and  ex- 
ternal plantar  arteries 
and  nerves. 

In  the  dorsal  flap 
are  cut  the  integu- 
ments, tibialis  anticus, 
extensor  commimis  di- 
gitorum, extensor  pro- 
prius  pollicis,  peroneus 
tevtius,  anterior  tibial 
vessels  and  nerve,  mus- 
culo-cutaneous  nerve,  and  internal  sapheuous  nerve 
and  vein.  The  position  of  the  principal  structuree 


Fig.  57.— Syme's  Amputation  (Agatz). 

a,  Tibia;  6,  fibula:  c,  tibinlis  anticus:  d, 
extensor  propriue  poliicis;  e,  extensor 
corcrannig digitorum  :  /•,  jicroneus  tertius; 
g.  flexor  longus  pollicis;  It,  tibialis  posti- 
cus ; !,  flexor  lungtu  disrnonim  ;j,  peroneus 
hrevis :  k,  peroneus  longus :  I,  tendo 
Aoliillis;  m,  some  muscles  of  the  sole  that 
are  not  usually  left  in  tliis  operation  ;  n, 
anterior  tibial  vessels  :  n,  posterior  tibial 
vessels  ;  p,  posterior  tibial  nerve. 


Chap,  xxiii.]      THE  ANKLE  AND  FOOT.  535 

divided  is  shown  in  Fig.  57.  It  is  not  usual  to  dissect 
up  any  of  the  muscular  tissue  of  the  sole,  as  shown 
in  Agatz's  plate.  It  should  be  noted  that  the  integu- 
ments of  the  heel  derive  their  blood  supply,  which  is 
very  free,  mainly  from  the  external  calcaneal  branch 
of  the  posterior  peroneal  artery,  and  the  internal 
calcaneal  from  the  external  plantar. 

If  the  heel  incision  is  carried  sufficiently  far  back 
to  divide  the  trunk  of  the  posterior  tibial  artery,  the 
heel  flap  is  deprived  of  the  last-named  source  of  blood 
supply.  The  posterior  tibial  artery  bifurcates  upon  a 
line  drawn  between  the  tip  of  the  inner  malleolus  and 
the  centre  of  the  convexity  of  the  heel. 

The  nerves  supplying  the  integuments  of  the  heel 
are  the  calcaneal  branch  of  the  external  saphenous 
and  the  calcaneal  and  plantar  cutaneous  twigs  from 
the  posterior  tibial. 

In  PirogoflPs  amputation  the  parts  divided 
in  the  anterior  flap  are  the  same  as  in  Syme's  operation. 
In  the  heel  or  sole  flap  the  same  structures  also  are 
cut  as  in  the  corresponding  flap  in  a  Syme,  with  the 
exception  that  the  tendo  Achillis  is  not  divided,  the 
flexor  brevis  digitorum,  abductor  pollicis,  abductor 
minimi  digiti,  and  flexor  accessorius  are  divided  more 
extensively,  and  the  plantar  vessels  are  cut  farther 
from  the  bifurcation. 

Chopart's  operation  is  an  amputation  at  the 
medio-tarsal  joint.  In  the  dorsal  flap  are  cut  the 
integuments,  the  extensor  communis  and  brevis  digi- 
torum, extensor  proprius  pollicis,  tibialis  anticus, 
peroneus  tertius  and  brevis,  the  musculo-cutaneous, 
anterior  tibial,  and  two  saphenous  nerves,  the  dorsal 
artery,  and  the  dorsal  plexus  of  veins.  In  the  plantar 
flap  are  found  divided  the  integuments,  plantar  fascia, 
flexor  brevis  digitorum,  abductors  of  the  great  and 
little  toes,  flexor  accessorius,  and  tibialis  posticus 
tendon.  If  the  flap  be  well  dissected  up  from  the 


536 


SURGICAL  APPLIED  ANATOMY.  [Chap.  xxm. 


bones,  parts  of  the  short  flexors  of  the  great  and  little 
toes,  the  adductor  pollicis,  and  transversus  pedis  will 
be  found  cut  in  the  flap.  The  tendons  of  the  long 

flexors  of  the  digits 
and  great  toes,  the 
peroneus  longus, 
and  the  plantar 
vessels  and  nerves 
are  also  divided 
(Fig.  58). 

L,is  franc's 


operation,  or  am- 
putation through 
the  tarso-metatarsal 
line  of  joints.  In 
the  dorsal  flap  the 
same  structures  are 
divided  as  are  cut 
in  the  correspond- 
ing flap  in  Clio- 
part's  amputation. 

Fig.  58,-Chopart's  Operation  (Agatz).         jn   tjie  plantar  flap 

a,  Astragalus;  &,  os  raids;  c,  extensor  proprius        l        j-l  i       J'     ' 

pollicis:  (I,  tibialis  antieus;  e,  extensor  com-     aiSO   tlie    pailS   divi- 


ded are  the  same  as 


munis  digitorum  ;  /.  pernncus  lontrus  ;  <7,ahduc- 
tor  minimi  digiti :  ft,  flexor  brevis  digitorum  ; 

/,  flexor  Ion t.'iis(liu'i torn m  :  /',  n  Ixl  11  nor  i  mil  iris  : 

k, flexor  lonirns  pollicis;  /.dorsalis  pcdisartery ;     111     tliat     procedure, 

m,  internal  plantar  artery ;  H,  external  plantar         -,i       ,1  ,  • 

artery.  with  the  exception 

that  the  flexor  ac- 

cessorius  and  the  tendon  of  the  tibialis  posticus  es- 
cape section.  In  opening  the  line  of  joints  it  should 
be  noted  that  the  articulations  between  the  three  outer 
metatarsals  and  the  corresponding  tarsal  bones  form  a 
line  sufficiently  straight  to  be  traversed  by  the  knife 
in  one  cut  when  once  the  blade  has  been  introduced. 

The  joint  also  between  the  first  metatarsal  and 
internal  cuneiform  bones  is  in  a  straight  line  and 
readily  opened.  The  most  difficult  part  of  the  dis- 
articulatioii  concerns  the  separation  of  the  second 


Chap,  xxiii.j     NERVES  OF  LOWER  LIMB. 


537 


metatarsal  bone,  which  is  deeply  lodged  between  the 
tarsal  segments.  The  chief  bond  of  union  between 
this  bone  and  the  tarsus  is  effected  by  a  strong 
iuterosseous  ligament 
that  passes  between 
it  and  the  internal 
cuneiform.  In  Fig.  59 
the  knife  is  placed  in 
the  position  required 
to  divide  that  liga- 
ment. 

In  the  subastra- 
galoid  amputa- 
tions a  disarticula- 
tion  is  effected  at  the 
astragalo-scaphoid  and 
astragalo  -  calcaneal 
joints.  The  astragalus 
is  the  only  bone  of  the 
foot  left  behind  and 
forms  the  summit  of 
the  stump. 

Fig.  60  shows  the 
position  of  the  more 
important  structures 
that  are  divided  in 
amputation  of  the 
great  toe  together  with 
its  metatarsal  bone. 

The  iiervc  sup- 
ply of  the  lower  limb. — In  Fig.  61  is  shown  the 
cutaneous  nerve-supply  of  the  inferior  extremities  on 
both  the  anterior  and  the  posterior  aspect.  Paralyses 
of  the  lower  limbs  are  common,  but  are  more  often 
due  to  some  lesion  in  the  inferior  segment  of  the  cord 
than  to  damage  received  by  any  one  individual  nerve. 
Cases,  however,  are  recorded  where  a  single  trunk  has 


Fig.  59.— Lisfraiic's  Operation  (Agatz). 

o,  *,  c.  Inner,  middle,  and  outer  cuneiform 
bones ;  d,  cuboid  :  c./,  the metntarsal  bones ; 
g,  tibialis  nnlicns;  A,  extensor  proprlui 
I  ml  lii-is  ;  i,  extensor  e.-nuuunis  (hint  or  tun  ; 
j,  extensor  brevis  difritnrtun  ;  fc,  extensor 
tendons ;  /,  dorsalig  i>edig  artery. 


538 


SURGICAL  APPLIED  ANATOMY.  [Chap.  xxm. 


been  injured  and  a  limited  form  of  paralysis  has 
followed  in  consequence. 

Paralysis    of  the    anterior    crural    nerve 

has  been  caused  by  injuries  to  the  lower  part  of  the 
vertebral  column  implicating  the  cauda  equina,  by 
fractures  of  the  pelvis,  by  tumours  of  the  pelvis,  by 
psoas  abscess,  by  fractures  aiitP dislocations"^!  the 


Fig.  60. — Amputation  of  Great  Toe,  with  its  Metatarsal  Bone  ..Agatz). 


a,  Internal  cuneiform  bone  ;  6,  adductor  pollicis:  c,  extensor  Iqngus  po'licis; 
d,  flexor  longus  pollicis ;  e,  plantar  branch  of  dorsalis  pedis  artery. 

femur,  and  by  stabs  in  the  region  of  the  groin.  In 
this  nerve  lesion  the  patient  is  unable  to  flex  the  hip 
and  to  raise  the  body  from  the  recumbent  position 
(ilio-psoas).  The  power  of  extending  the  leg  at  the 
knee  is  lost  (quadriceps  extensor  cruris)  ;  the  function 
of  the  sartorius  is  destroyed  and  that  of  the  pectineus 
impaired.  Sensation  is  impaired  in  parts  supplied  by 
the  internal  and  middle  cutaneous  nerves  and  the  long 
saphenous  nerve. 

Paralysis  of  the  obturator  nerve  alone  is  a 
rare  condition,  although  it  may  be  found  associated 
with  a  like  lesion  of  the  preceding  trunk.  It  may  be 
brought  about  by  the  pressure  exercised  upon  the  nerve 
in  cases  of  obturator  hernia  and  by  the  foetal  head 


539 


5  \ 


6  I 


Fig.  61. — Cutaneous  Nerve-Supply  of  Lower  Limb. 


Anterior  Aspect.— \.\\\n-\nairinA\  ;2,genito-crurnl ; 3,  external  cutaneous:  4, middle 
cutaneous  ;  5,  internal  cutaneous;  6,  jwiti'llar  plexus  ;  7,  branches  of  external 
popliteal;  8,  internal  MgkOKHUi  9,  luusculo cutaneous ;  10,  external  saphe- 
nnus  ;  11,  anterior  tibi.il. 

Porteriirr  A*pect.—\,  2,  and  S,  small  sciatic:  4,  external  cutaneous:  5,  internal 
cutaneous;  6,  internal  MpbCOOQI ;  7,  branches  of  external  popliteal ;  8,  short 
saphenous  :  9.  pi'Sterior  tibial ;  10,  internal  saphenous  ;  11,  internal  plantar; 
12,  external  plantar. 


540          SURGICAL  APPLIED  ANATOMY.  [Chap.  xxin. 

during  delivery.  The  muscles  implicated  are  the 
adductors,  gracilis,  pectineus,  and  external  obturator. 
The  patient  is  unable  to  press  the  knees  together,  or 
to  cross  the  legs.  Rotation  outwards  is  difficult,  arid 
sensation  is  affected  in  the  skin  supplied. 

Paralysis  of  the  internal  popliteal  nerve. 
— There  is  inability  to  extend  the  ankle  and  to  flex  the 
toes  (flexor  longus  digitorum,  flexor  proprius  pollicis, 
tibialis  posticus,  gastrocuemius,  and  soleus).  The 
patient  is  unable  to  stand  upon  the  toes  owing  to  loss 
of  function  in  the  two  last-named  muscles.  The 
power  of  adducting  the  foot  and  of  raising  its  inner 
border  is  impaired  (tibialis  posticus),  and  lateral  move- 
ments in  the  toes  are  lost  owing  to  paralysis  of  all  the 
'small  muscles  of  the  sole.  Sensation  is  impaired  over 
the  plantar  aspect  of  the  toes,  the  sole,  and  in  part  of 
the  lower  half  of  the  back  of  the  leg. 

In  paralysis  of  the  external  popliteal  nerve 
the  action  of  the  muscles  on  the  front  of  the  leg  is 
lost.  The  foot  hangs  down  and  the  toes  catch  the 
ground  in  walking.  The  foot  can  be  neither  flexed 
nor  abducted  (extensor  communis  digitorum,  extensor 
proprius  pollicis,  peroneal  muscles).  Adduction  is  im- 
perfect, owing  to  paralysis  of  the  tibialis  anticus. 
Extension  of  the  toes  is  only  possible  to  the  slight 
extent  effected  by  the  interossei.  The  arch  of  the  foot 
becomes  flattened  owing  to  loss  of  the  support  furnished 
by  the  peroneus  longus.  Sensation  is  impaired  over 
the  front  and  outer  side  of  the  leg  and  on  the  dorsum 
of  the  foot,  and  also  some  part  of  the  back  of  the  leg, 
owing  to  paralysis  of  the  communicans  peronei. 

When  the  great  sciatic  nerve  is  paralysed 
there  will  be,  in  addition  to  the  loss  of  function  in  the 
two  preceding  nerves,  an  inability  to  flex  the  knee, 
owing  to  paralysis  of  the  hamstrings,  while  rotation 
of  the  limb  may  be  impaired  by  loss  of  power  in  the 
quadratus  femoris  and  obturator  intei-nus. 


CHAPTER   XXIV. 

THE   SPINE. 

THE  vertebral  column  combines  in  a  remarkable 
way  many  very  different  and  complicated  functions. 
It  acts  as  the  central  pillar  of  the  body,  and  as  the 
column  that  supports  the  weight  of  the  head.  It 
connects  the  upper  and  lower  segments  of  the  trunk. 
It  gives  attachments  to  the  ribs.  It  has  the  property 
of  mitigating  the  effects  of  shocks  that  are  transmitted 
from  various  parts  of  the  body.  It  permits,  to  a 
wonderful  degree,  of  a  number  of  most  complicated 
movements ;  and,  lastly,  forms  a  solid  tube  for  the 
reception  of  the  spinal  cord. 

It  owes  much  of  its  elasticity,  and  of  its  power 
of  breaking  up  divers  forces  communicated  to  it,  to 
its  curves.  Of  the  four  curves,  two,  the  dorsal  and 
sacral,  are  primary,  are  due  to  the  formation  of  the 
thoracic  and  pelvic  cavities,  and  depend  mainly  upon 
the  shape  of  the  bones.  The  other  two,  the  cervical 
and  lumbar,  are  compensatory  curves,  and  depend 
mainly  upon  the  shape  of  the  intervertebral  discs. 
The  dorsal  and  sacral  curves  appear  in  fretal  life  ;  the 
lumbar  and  cervical  curves  appear  after  birth,  and 
depend  on  the  assumption  of  the  erect  position.  The 
infant's  spine  appears  straight.  The  only  marked 
curve  seen  in  the  back  of  the  young  child  is  a  general 
curving  of  the  column  backwards,  a  cyphosis.  When 
the  infant  is  first  encouraged  to  sit  erect,  this  is  tho 


542          SURGICAL  APPLIED  ANATOMY.  [Chap.  xxiv. 

outline  assumed  by  the  spine,  and  in  some  weakly 
children,  and  especially  in  those  afflicted  with  rickets, 
this  curvature  is  often  very  pronounced.  The  discs 
are  twenty-three  in  number,  and  make  up  nearly  one- 
fourth  of  the  entire  length  of  the  spine.  If  the  discs 
be  removed,  and  the  vertebrae  be  articulated  in  the 
dry  state,  the  cervical  and  lumbar  convexities  almost 
disappear,  and  the  column  tends  to  present  one  great 
curvature,  the  concavity  of  which  is  forwards,  and  the 
most  marked  part  of  which  corresponds  to  a  point  just 
below  the  middle  of  the  dorsal  region.  This  somewhat 
resembles  the  curve  seen  in  the  spines  of  the  aged,  and 
in  such  individuals  it  may  be  to  no  small  extent  due 
to  the  shi'inking  of  the  inter  vertebral  discs. 

It  is  by  means  of  the  discs  that  the  movements  of 
the  spine  are  in  the  main  permitted,  and  it  will  be 
found  that  they  are  most  developed  in  regions  where 
most  movement  is  allowed.  They  act  also  as  springs 
in  giving  elasticity  to  the  column,  and  in  economising 
muscular  action,  while  at  the  same  time  they  play  the 
part  of  buffers  in  modifying  the  effect  of  shocks  trans- 
mitted along  the  spine. 

Although  the  motion  permitted  between  any  two 
individual  vertebrae  is  not  extensive,  yet  the  degree  of 
movement  capable,  of  being  exercised  in  the  column 
as  a  whole  is  considerable.  This  movement  is  least 
free  at  the  dorsal  region,  and  is  most  extensive  in  the 
neck  and  loins.  In  the  lumbar  region  (the  base  of 
the  column)  exists  the  greatest  degree  of  motion  per- 
mitted in  the  spine,  and  here  is  allowed,  not  only 
forward  and  backward  flexion,  but  also  lateral  bending, 
and  a  certain  amount  of  rotation.  In  the  cervical 
region  flexion  in  the  antero-posterior  direction  is  not 
so  ready  as  it  is  in  the  loins,  although  the  neck  enjoys 
the  greatest  degree  of  rotation  and  of  lateral  flexion. 

Sprains  of  the  vertebral  column. — The  many 
joints  and  ligaments  of  the  part,  and  the  varied  and 


Chap,  xxiv.1  THE  SPINE.  543 

violent  movements  to  which  it  may  be  exposed,  render 
it  very  liable  to  be  the  seat  of  sprains.  These  injuries, 
however,  cannot  reach  any  great  magnitude,  for  so 
closely  are  the  individual  vertebrae  articulated,  that 
any  force  severe  enough  to  produce  other  than  slight 
tearing  of  the  ligaments  will  tend  to  cause  a  fracture 
or  dislocation  of  the  bones. 

Sprains  are  most  commonly  met  with  in  the  cervical 
and  lumbar  segments  of  the  spine.  This  localisation 
is  due  to  the  mobility  of  those  parts,  and  to  their 
tendency  to  diffuse  any  violence  transmitted  to  them, 
and  so  to  render  it  more  general.  For  it  is  to  be  noted 
that  the  more  localised  an  injury,  the  more  likely  it 
is  to  produce  a  fracture  or  dislocation  rather  than  a 
sprain. 

In  the  cervical  region,  also,  the  tendency  to  sprain 
is  increased  by  the  near  articulation  of  the  column 
with  the  head,  and  the  possibility  of  any  violence 
applied  to  the  skull  being  transmitted  to  the  spine. 

Sprains  of  the  spine  are  not  apt  to  be  associated 
with  the  external  evidences  of  ecchymosis,  since  be- 
tween the  skin  and  the  column  there  intervene  not 
only  many  layers  of  muscles,  but  also  dense  expan- 
sions of  fascia. 

It  has  already  been  pointed  out  that  sprains  in  the 
loin,  produced  by  severe  bending  forwards  of  the 
column,  may  be  associated  with  some  damage  to  the 
kidney,  and  consequent  hsernaturia  (page  362). 

A  sprained  back  is  often  the  seat  of  a  considerable 
degree  of  pain  and  stiffness,  that  persists  long  after 
the  immediate  effects  of  the  lesion  must  have  passed 
away.  Such  a  condition  may  be  understood  by  noticing 
that  the  column  presents  a  vast  number  of  separate 
articulations,  each  provided  with  cartilage,  synovial 
membrane,  and  capsular  ligaments.  These  joints  have 
no  qualities  that  exempt  them  from  the  common  evils 
incident  to  sprains  of  more  superficial  articulations  ; 


544  SURGICAL  APPLIED  ANATOMY.  [Chap.  xxiv. 

and  there  is  little  doubt  that  the  long-felt  pain  and 
inconvenience  often  depend  upon  some  synovitis  of 
the  vertebral  joints.  In  a  few  cases  this  synovitis 
has  gone  on  to  suppuration,  and  in  one  instance  at 
least  the  pus  so  formed  found  its  way  into  the 
spinal  canal,  and  induced  some  mischief  in  the  cord. 

Fractures  and  dislocations  of  the  spine. — 
The  effects  of  violence  applied  to  the  column  are  much 
diminished  by  the  general  elasticity  of  the  spine,  by  its 
curves,  and  by  the  circumstance  that  it  is  composed 
of  a  number  of  separate  segments.  Each  vertebra 
meets  the  one  immediately  above  or  below  it  at  three 
points  of  contact,  the  body  and  the  two  articulating 
processes.  The  bodies  are  separated  by  the  inter- 
vertebral  disc,  which  acts  as  an  excellent  spring  or 
buffer  in  modifying  the  effects  of  violence.  The  ar- 
ticulating processes  are  more  or  less  wedge-shaped,  the 
thin  edge  of  one  being  applied  to  the  base  of  the  other. 
When  a  force  is  applied  to  the  column  that  tends  to 
compress  the  vertebra?  together,  the  bases  of  the  two 
wedges  are  brought  in  more  and  more  close  relation, 
and  thus  an  increasing  resistance  is  offered  to  the  com- 
pressing power. 

The  parts  of  the  spine  most  liable  to  injury  are 
(1)  the  atlo-axial ;  (2)  the  cervico-dorsal ;  and  (3)  the 
dorso-lumbar.  In  the  atlo-axial  region  the  parts  not 
only  enjoy  a  very  considerable  degree  of  movement, 
but  are  very  directly  influenced  by  many  forms  of 
violence  applied  to  the  head.  In  the  two  other  regions 
it  will  be  noted  that  a  flexible  part  of  the  spine  joins  a 
comparatively  rigid  segment  of  it,  and  thus  violence 
applied  to  the  column  in  either  of  these  districts  is 
apt  to  be  concentrated  rather  than  diffused.  The 
mechanism  is  in  a  way  illustrated  by  the  circumstance 
that  a  fishing-rod  when  it  snaps  commonly  breaks  near 
a  joint,  that  is  to  say,  at  a  spot  where  a  flexible  seg- 
ment of  the  rod  meets  a  less  elastic  poi'tion.  In  the 


Chnp.xxiv.j  THE  SPINE.  545 

dorso-lumbar  region,  moreover,  the  vertebrae,  although 
they  have  to  support  almost  as  much  weight  as  have 
those  of  the  lumbar  region  proper,  are  yet  dispropor- 
tionately small  in  size.  Being  placed,  also,  near  the 
middle  of  the  column,  they  can  be  influenced  on  all 
sides  by  a  powerful  amount  of  leverage.  The 
gravity  of  all  injuries  to  the  spine  depends  upon  the 
risk  of  damage  to  the  cord  enclosed  in  the  column. 
Apart  from  this  complication,  fractures  and  disloca- 
tions in  this  region  are  apt  to  do  well,  and  if  the 
patient  survive,  the  former  lesions  nearly  always  heal 
readily. 

The  position  of  the  cord  within  the  vertebral 
canal  and  the  arrangement  of  its  membranes  are  such 
that  it  presents  many  facilities  for  escaping  injury 
from  violence.  These  will  be  dealt  with  subsequently 
in  speaking  of  the  cord  itself.  It  may,  however, 
be  noted  here  that  the  construction  of  the  vertebrae, 
and  their  relation  to  one  another,  are  of  a  character 
to  afford  much  protection  to  the  cord,  even  in  cases 
where  they  themselves  are  extensively  damaged. 
"  Being  lodged  in  the  centre  of  the  column,  it  (the 
cord)  occupies  neutral  ground  to  forces  which  might 
cause  fracture.  For  it  is  a  law  in  mechanics  that  when 
a  beam,  as  of  timber,  is  exposed  to  breakage,  and  the 
force  does  not  exceed  the  limits  of  the  strength  of  the 
material,  one  division  resists  compression,  another 
laceration  of  the  particles,  while  the  third,  between  the 
two,  is  in  a  negative  condition."  (Jacobson,  Holmes' 
"System ").  Now,  it  happens  that  fractures  of  the  spine 
are  most  often  due  to  violence  that  bends  the  column 
forwards.  The  anterior  segment,  in  such  a  case,  will 
be  subject  to  compression,  the  posterior  to  laceration, 
and  the  intermediate  portion  will  be  in  a  neutral  con- 
dition. When  the  spine  is  examined,  it  will  be  found 
that  its  anterior  part,  composed  of  the  large  cancellous 
bodies,  is  excellently  adapted  to  resist  the  effects  of 

jj— 4 


546  SURGICAL  APPLIED  ANATOMY.  .{Chap.  xxiv. 

compression,  while  its  posterior  parts,  composed  of 
slighter  and  more  compact  bones  and  surrounded  by 
many  strong  ligaments,  are  well  arranged  to  resist  the 
effects  of  a  tearing  force.  The  spinal  cord,  situated 
between  these  two  divisions,  occupies  the  position  of 
least  danger. 

The  vertebrae  may  be  fiactured  without  being  dis- 
located, but  a  dislocation  without  a  fracture  is  rarely 
possible. 

It  would  appear,  indeed,  that  a  luxation  of  the 
spine,  with  no  fracture  of  bone,  cannot  occur  in  either 
the  dorsal  or  lumbar  regions.  Mr.  Jacobson,  in  the 
essay  above  referred  to,  writes,  "  \  believe  I  am  correct 
in  stating  that  there  is  no  case  recorded,  and  thoroughly 
^verified,  in  recent  years,  of  dislocation  of  the  lumbar 
or  dorsal  vertebi-se,  unaccompanied  with  any  fracture 
of  the  body,  transverse  or  articular  processes."  Dislo- 
cation without  fracture  has  been  met  with  in  the 
cervical  spine,  although  even  there,  if  we  except 
the  first  two  vertebrae,  it  is  very  rare.  When  it 
occurs  it  most  often  involves  the  fifth  vertebra,  which, 
with  the  rest  of  the  column  above  it,  is  displaced  for- 
wards and  downwards.  Luxations  in  other  directions 
have  been  noted,  but  they  are  extremely  uncommon. 
The  possibility  of  luxation  in  the  cervical  region  with- 
out dislocation  is  explained  by  the  small  size  of  the 
vertebral  bodies,  the  obliquity  of  their  articular  pro- 
cesses, and  the  relatively  slight  opposition  they  offer 
to  displacement  when  compared  with  like  processes  in 
the  other  parts  of  the  column.  The  luxation  is  usually 
bilateral  and  incomplete,  and  the  result  of  a  forcible 
bending  of  the  head  and  upper  part  of  the  spine  for- 
wards and  downwards.  When  situated  high  up  the 
displacement  may  be  appreciated  by  an  examination 
of  the  part  through  the  pharynx.  In  the  complete 
bilateral  dislocation  the  cord  is  usually  hopelessly 
crushed.  These  luxations  have  seen  reduced  by  forcible 


Cha;>.  XXIV.J  THE   SPINE.  547 

extension,  although  the  circumstances  under  which 
such  a  procedure  is  advisable  are  neither  frequent 
nor  very  distinctly  marked. 

Since,  in  severe  injuries,  dislocation  and  fracture 
are  so  usually  associated,  it  is  common  to  deal  with 
these  lesions  under  the  title  of  "fracture-dislocation." 

Fracture-dislocation  may  be  due  to  (1)  indirect, 
or  (2)  direct  violence  1.  The  injuries  from  indirect 
violence  are  by  far  the  more  common.  They  are  due 
to  a  violent  bending  of  the  head,  or  of  the  spine  above 
the  seat  of  lesion,  forwards  and  downwards.  Thus, 
the  cervical  spine  has  been  more  than  once  broken  by  a 
"header"  into  shallow  water;  while  the  dorsal  vertebrae 
have  been  fractured  and  displaced  by  the  acute  bending 
of  the  column,  produced  by  a  heavy  sack  falling  upon 
the  back  of  the  neck. 

This  form  of  injury  is  most  commonly  met  with  in 
the  cervical  and  upper  dorsal  regions.  These  parts  of 
the  column  possess  great  mobility,  the  bodies  that 
compose  th'em  are  not  large,  and  are  influenced  by 
violence  applied  to  the  head.  In  a  well- marked  case 
there  is  some  crushing  of  the  vertebrae  involved,  and 
the  usual  deformity  depends  upon  a  sliding  of  the 
centrum  above  downwards  and  forwards  upon  the 
centrum  below.  Complete  displacement  of  any  two 
vertebrae  from  one  another  is  prevented  by  a  locking 
of  the  posterior  processes.  In  some  cases  the  luxation 
is  complete,  a  condition  that  is  least  frequently  met 
with  in  the  lumbar  spine. 

In  the  cervical  and  dorsal  regions,  the  parts,  after 
the  dislocation,  may  often  be  returned  to  their  normal 
position ;  but  in  the  loins  this  replacement  is  usually 
impossible,  owing  to  the  locking  of  the  large  and 
powerful  articular  processes.  In  the  neck  the  laminae 
and  spines  may  be  fractured,  while  the  articulating 
processes,  being  broad  and  nearly  horizontal,  usually 
escape,  even  when  there  is  much  displacement  of  the 


548  SURGICAL  APPLIED  ANATOMY.  [Chap.  xxiv. 

parts.  In  the  dorsal  spine  the  laminae  and  articular 
processes  are  always  torn  when  displacement  occurs. 
In  the  lumbar  region  the  articular  processes  usually 
escape  fracture,  although  they  are  violently  torn 
asunder.  In  all  cases  there  is  more  or  less  laceration 
of  the  intervertebral  discs,  the  supraspinous,  inter- 
spiiious,  and  capsular  ligaments  are  torn,  as  are  also 
the  ligamenta  subflava.  When  the  bodies  are  much 
crushed  and  displaced  the  anterior  and  posterior 
common  ligaments  are  commonly  ruptured. 

2.  In  the  fracture  -  dislocations  due  to  direct 
violence  the  lesion  may  be  at  any  part  of  the  spine. 
Some  form  of  direct  violence  is  applied  to  the  back, 
and  the  column  tends  to  become  bent  backwards  at 
the  spot  struck.  In  the  previous  class  of  injuries  it 
will  be  noted  that  the  anterior  segments  of  the  ver- 
tebrae suffer  compression,  while  the  posterior  suffer 
from  the  effects  of  laceration  and  a  tearing  asunder  of 
their  parts.  In  lesions  due  to  direct  violence  the 
circumstances  of  the  injury  are  reversed,  the  posterior 
segments  tend  to  be  crushed  together,  while  the  bodies 
on  the  front  of  the  spine  are  separated. 

Much  displacement  is  very  rarely  met  with  in  thifc 
form  of  accident.  To  produce  separation  of  the  ver- 
tebrae the  violence  must  be  very  extreme,  and  as  a 
rule  the  force  expends  itself  upon  a  crushing  of  the 
hinder  portions  of  the  spinal  segments.  It  follows 
from  this,  also,  that  injury  to  the  cord  is  less  common 
and  less  severe  in  lesions  due  to  direct  violence  than 
in  those  due  to  indirect  violence.  In  the  atlo-axial 
region  the  atlas  and  occipital  bone  have  been  dislocated 
from  one  another  by  direct  violence,  although  the 
most  frequent  lesion  is  a  dislocation  of  the  former 
forwards  upon  the  axis,  a  lesion  usually,  if  not  always, 
associated  with  fracture  of  the  odontoid  process. 

The  spinous  processes  may  be  broken  off  as  a  ro- 
sult  of  well-localised  blows.  The  prominent  spines  in 


chap,  xxiv.i  THE  SPINE.  549 

the  lower  cervical  region  and  the  long  processes  of  the 
dorsal  tract  of  the  column  are  those  that  usually  suffer. 
The  lumbar  spines  are  less  frequently  broken,  being 
comparatively  small  and  well  protected  by  the  great 
muscles  of  the  back. 

The  transverse  processes  and  laminae  can  scarcely 
1)6  fractured  alone. 

In  several  instances  of  fracture-dislocation  and  of 
fracture  alone  the  spine  has  been  trephined,  or  rather 
portions  of  the  laminae  and  spinous  processes  have 
been  resected  (Laminectomy).  By  this  means  the 
spinal  canal  has  been  freely  opened  up,  effused  blood 
has  been  allowed  to  escape,  and  the  cord  has  been 
freed  from  pressure.  The  laminae  are  divided  as  near 
the  transverse  process  as  possible,  and  the  tough 
ligamenta  subflava  require  careful  division.  Dr. 
White,  of  Philadelphia,  has  collected  (1889)  thirteen 
recent  examples  of  operation  for  fracture  with  only 
one  death. 

The  column  is  reached  through  a  median  incision, 
and  the  great  muscular  masses  are  cleared  from  the 
spinous  processes  and  laminae  on  either  side.  The 
wound  being  nearly  median,  the  bleeding  is  not 
excessive. 

This  operation  has  also  been  carried  out  with 
success  in  cases  of  paralysis  due  to  the  pressure  upon 
the  cord  by  displaced  bone  or  inflammatory  exudations, 
in  caries  of  the  spine  (Pott's  disease).  It  has  to  be 
noted,  however,  in  the  last-named  class  of  case,  that 
the  condition  exhibits  a  tendency  to  spontaneous  cure. 

The  spinal  cord  is  in  the  adult  about  eighteen 
inches  in  length,  and  extends  from  the  lower  margin 
of  the  foramen  magnum  to  the  lower  edge  of  the  body 
of  the  first  lumbar  vertebra.  In  some  cases  it  ends  at 
the  second  lumbar,  and  in  other  instances  at  the  last 
dorsal  vertebra.  It  is  to  be  noted  also  that  in  flexion 
of  the  spine  the  cord  is  a  little  raised.  In  the  earlier 


§5°  SURGICAL  APPLIED  ANATOMY.  [Chap,  xxiv: 

months  of  foetal  life  the  medulla  spinalis  occupies  the 
whole  length  of  the  vertebral  canal,  but  after  the  third 
month  the  canal  and  lumbar  and  sacial  nerves  grow 
so  much  faster  than  does  the  cord  itself,  that  by  the 
time  of  birth  it  reaches  no  farther  than  the  third 
lumbar  vertebra.  It  is  obviously  a  great  advantage, 
in  cases  of  injury,  that  the  spinal  medulla  does 
not  occupy  that  part  of  the  vertebral  pillar  which  joins 
the  base  of  the  column,  and  which  permits  not  only 
of  considerable  movement,  but  is  liable  also  to  frequent 
wrenches  and  strains.  It  is  important  to  recollect 
that  although  the  cord  itself  ends  at  the  spot  indicated, 
the  dura  mater,  the  arachnoid,  and  the  collection  of 
cerebro-spinal  fluid  extend  as  far  as  the  second  piece 
of  the  sacrum.  Injuries  inflicted,  therefore,  upon  the 
spine  as  low  down  as  this  latter  point,  may  cause  death 
by  inducing  inflammation  of  the  meninges.  The  cord 
in  the  dorsal  region  measures  about  10  mm.  from  side 
to  side,  and  8  mm.  in  the  antero-posterior  direction. 
The  cervical  enlargement  is  largest  opposite  the  fifth 
or  sixth  cervical  vertebrae,  where  it  meastu-es  about 
13  mm.  from  side  to  side.  The  greatest  part  of  the 
lumbar  enlargement  is  opposite  the  twelfth  dorsal 
vertebra,  where  its  lateral  measurement  is  about 
12  mm. 

The  spinal  dura  mater  is  a  strong  and  substantial 
membrane,  and  between  it  and  the  walls  of  the  ver- 
tebral canal  a  considerable  space  exists  occupied  by 
loose  areolar  tissue  and  a  plexus  of  veins.  It  will  be 
readily  understood  that  injury  and  inflammation  of 
the  meninges,  as  results  of  lesions  applied  to  the  spine, 
are  much  less  frequent  than  are  like  complications 
after  injuries  to  the  skull.  The  looseness  of  the  spinal 
dura  mater,  its  freedom  from  any  but  slight  and 
occasional  attachments  to  the  bone,  and  the  space 
around  it  in  which  effusions  can  extend  with  little 
possibility  of  becoming  limited,  will  explain  the  rarity 


Chap,  xxiv.]  THE  SPINE.  551 

in  the  spine  of  those  complications  which  follow  upon 
depressed  bone,  and  extravasations  of  pus  and  blood  in 
connection  with  the  dura  mater  within  the  skull.  The 
plexus  of  thin- walled  veins  that  occupies  the  interval 
between  the  theca  and  the  bones  may  prove  a  source 
of  extensive  haemorrhage  in  cases  of  injury  to  the 
column.  The  blood  so  poured  out  tends  to  gravitate 
to  the  lowest  part  of  the  canal,  and  when  sufficient  in 
quantity  may  produce  pressure  effects  upon  the  me- 
dulla spinalis. 

Over  the  arches  at  the  posterior  aspect  of  the  ver- 
tebrae is  situate  a  plexus  of  vessels  (the  dorsal  spinal 
veins)  that  receives  blood  from  the  muscles  and  inte- 
guments of  the  back.  These  vessels  communicate 
through  the  ligamenta  subflava  with  the  venous 
plexuses  within  the  spinal  canal,  and  by  means  of 
tins  communication  inflammation  from  without  may 
be  conducted  to  the  theca  of  the  cord.  Thus  spinal 
meningitis  has  followed  upon  deep  bed-sores,  and  upon 
suppurative  affections  situated  in  the  immediate 
vicinity  of  the  spinal  laminae. 

Within  the  dura  mater  are  two  spaces,  the  sub- 
dural  and  the  subarachnoid,  as  in  the  skull.  They 
are  occupied  by  a  considerable  quantity  of  cerebro- 
spinal  fluid,  continuous  with  the  collection  within  the 
cranium.  By  means  of  this  open  communication  inflam- 
matory affections  may  readily  spread  from  the  cord  to 
the  brain.  Into  these  spaces  blood  may  be  extrava- 
sjited  in  cases  of  injury.  Instances  have  been  recorded 
where  the  theca  has  been  opened  by  a  wound,  and  the 
cerebro-spinal  fluid  has  escaped  in  large  quantities. 

The  position  of  the  cord  is  such  that  it  is  not 
readily  reached  in  incised  and  punctured  wounds.  The 
only  spots  at  which  it  is  easy  of  access  are  the  intervals 
between  the  atlas  and  occiput  and  the  atlas  and  axis. 
Many  cases  have  been  recorded  of  fatal  wound  of  the 
cord  in  these  positions.  Lower  down  in  the  column 


552  SURGICAL  APPLIED  ANATOMY.  [Chap.  xxiv. 

the  medulla  spinalis  may  be  reached  if  the  wound  have 
a  certain  direction.  Thus,  a  case  is  reported  where  a 
pointed  body  entered  the  canal  between  the  ninth  and 
tenth  dorsal  vertebrae,  having  been  introduced  from 
below  upwards. 

Several  examples  of  damage  to  the  cord  by  sword 
or  bayonet  wounds  have  been  put  on  record,  but  in 
most  of  these  instances  the  wound  was  associated  with 
some  fracture  of  the  protecting  bone. 

Concussion  of  the  cord. — After  certain  in 
juries  to  the  back  a  train  of  symptoms,  usually  of  a 
severe  and  complicated  character,  have  been  described, 
which  have  been  assigned  to  a  concussion  or  shaking 
of  the  spinal  cord. 

In  these  injuries  it  is  assumed  that,  as  a  result  of 
a  sudden  shock  transmitted  to  it,  the  cord  undergoes 
certain  molecular  changes,  which  lead  to  a  more  or 
less  severe  disturbance  of  its  function.  The  condition 
has  been  compared  to  concussion  of  the  brain,  al- 
though it  must  be  owned  that  the  symptoms  often 
accredited  to  concussion  of  the  cord  have  a  character 
more  complex  than  that  seen  in  like  lesions  of  the 
more  complex  organ. 

A  great  many  surgeons  are  inclined  to  dispute  the 
existence  of  this  lesion,  or  rather  decline  to  recognise 
the  connection  between  a  certain  train  of  symptoms 
and  a  simple  molecular  disturbance  of  the  cord.  It  is 
very  probable  that  in  many  of  the  reputed  instances  of 
cord-concussion  the  symptoms  (if  we  except  such  as 
are  assumed  and  such  as  depend  upon  changes  in  the 
brain)  are  due  to  a  more  distinct  damage  to  the  medulla 
spinalis,  to  haemorrhages,  to  pressure,  and  to  other 
gross  changes.  Without  entering  into  any  discussion 
upon  the  subject,  it  maybe  sufficient  to  point  out  some 
of  the  anatomical  objections  that  appear  to  oppose 
themselves  to  the  common  conception  of  concussion  of 
the  cord.  The  spinal  cord  is  swung  or  susperded  in 


chap,  xxiv.i  THE  SPINE,  553 

its  bony  canal,  and  is  separated  from  the  walls  of  that 
canal  on  all  sides  by  a  considerable  interval.  It  is, 
indeed,  only  held  in  position  by  the  nerve  trunks  that 
pass  out  from  it  through  the  interv  ertebral  foramina, 
and  by  its  connections  with  the  theca.  Above,  it  is 
connected  with  that  part  of  the  brain  that  lies  upon 
the  largest  intraeranial  collection  of  the  cerebro-spinal 
fluid  (page  31),  and  it  would  appear  that  the  most 
violent  movements  possible  of  the  brain  within  the 
skull  could  be  but  very  feebly  communicated  to  the 
spinal  cord.  The  cord,  moreover,  within  its  theca,  is 
surrounded  on  all  sides  by  a  space  occupied  by  cerebro- 
spinal  fluid.  It  is  difficult  to  understand,  therefore, 
how  a  structure  so  protected  can  be  so  violently  dis- 
turbed by  a  shock  received  upon  the  body  as  to  undergo 
a  grave  and  progressive  loss  of  function.  The  cord  is, 
indeed,  somewhat  in  the  position  of  a  caterpillar  sus- 
pended by  a  thread  in  a  phial  of  water.  It  would 
probably  be  difficult  to  permanently  disturb  the  in- 
ternal economy  of  such  an  insect  (even  if  it  had  a 
structure  as  elaborate  as  the  cord)  by  other  than  vio- 
lence that  would  be  comparatively  excessive. 

Contusion  and  crushing  of  the  cord. — As 
has  been  already  observed,  the  gravity  of  fractures  and 
dislocations  of  the  spine  depends  upon  the  extent  of 
the  damage  received  by  the  cord.  In  these  accidents 
it  is  very  usual  for  some  part  of  the  injured  vertebrae 
to  be  projected  into  the  spinal  canal,  so  as  to  press 
upon  or  actually  crush  the  delicate  nerve  centre  that 
it  contains. 

It  is  needless  to  observe  that  the  cord  is  extremely 
soft,  and  thus  it  happens  that  it  may  be  entirely  broken 
up  by  violence  without  the  membranes  being  percep- 
tibly damaged.  Indeed,  in  fracture-dislocations  it  is 
unusual  for  the  theca  to  be  torn,  and  it  is  possible  for 
the  cord  to  be  quite  crushed  at  some  one  spot  without 
the  corresponding  pia  mater  being  in  any  way  lacerated. 


§54  SURGICAL  APPLIED  ANATOMY.  [Chap,  xxiv 

The  amount  of  damage  inflicted  upon  the  cord  will 
vary,  of  course,  with  the  magnitude  of  the  accident ; 
but,  other  things  being  equal,  it  will  be  found  to  be 
more  severely  injured  in  fracture-dislocations  of  the 
cervical  and  dorsal  segments  than  in  like  lesions  in  the 
lumbar  spine.  In  the  atlo-axial  region  the  amount  of 
displacement  that  follows  upon  luxation  of  the  t\ro 
bones  from  one  another  is  such  that  the  cord  is,  as  a 
rule,  severely  crushed,  and  death  ensues  instantaneously, 
as  is  seen  in  cases  of  death  by  hanging.  In  the  cervical 
and  upper  dorsal  segments  of  the  column  the  vertebral 
bodies  are  small,  the  spine  is  mobile,  the  fractures 
met  with  in  the  parts  are  usually  due  to  indirect 
-violence,  and  are  associated  with  much  displacement. 
In  the  lower  dorsal  region,  again,  the  greater  rigidity 
of  the  spine  renders  any  displacement,  when  it  does 
occur,  likely  to  be  considerable.  In  the  lumbar  region, 
on  the  other  hand,  it  must  be  noted  that  the  cord  only 
extends  to  the  lower  border  of  the  first  vertebra.  The 
bodies  of  the  vertebrae,  also,  in  this  district,  are  very 
large  and  cancellous,  and  can  undergo  a  severe  amount 
of  crushing  without  a  corresponding  degree  of  dis- 
placement being  produced.  The  part  is  also  well 
protected  by  the  large  intervertebral  discs,  and  by  the 
immense  masses  of  muscle  that  surround  the  spine  in 
the  loins.  Such  portion  also  of  the  spinal  medulla  as 
extends  into  the  lumbar  region  is  protected  by  tho 
many  cords  of  the  cauda  equina,  which,  by  their  loose- 
ness and  comparative  toughness,  tend  to  minimise  the 
effects  of  violence. 

The  degree  of  displacement  of  bone  required  to 
produce  pressure  effects  upon  the  cord  is  often  greater 
than  would  be  supposed.  At  post-mortem  examina- 
tions portions  of  injured  vertebrae  have  been  found 
encroaching  upon  the  spinal  canal  to  a  considerable 
extent  in  cases  where  no  evidences  of  damage  to  the 
cord  existed  during  life.  Dr.  J.  W.  Ogle  reports  the 


CW  JcxiV.)  THE  SPINE.  $55 

case  of  a  man  who,  after  an  injury  to  the  neck  from 
a  fall,  presented  no  spinal  symptoms  until  three  days 
had  elapsed.  He  ultimately  became  paralysed,  and 
died  thirty-two  days  after  the  accident.  The  autopsy 
revealed  a  dislocation  forwards  of  the  sixth  cervical 
vertebra,  of  such  an  extent  that  the  body  below 
projected  at  least  half  an  inch  into  the  spinal 
canal. 

The  remarkable  manner  in  which  the  cord  will 
accommodate  itself  to  a  slowly  progressing  pressure  is 
often  well  seen  in  the  results  of  chronic  bone  disease 
in  the  column. 

The  symptoms  due  to  injury  to  the  cord  and  to  the 
nerves  contained  in  the  spinal  canal,  will  obviously 
depend  from  the  situation  and  extent  of  the  lesion. 
The  diagnosis  of  the  situation  of  the  lesion  is  compli- 
cated by  the  relation  the  nerves  bear  to  the  various 
vertebrae,  and  by  the  fact  that  the  majority  of  the 
great  trunks  arise  from  the  cord  at  a  spot  above  the 
point  at  which  they  issue  from  the  vertebral  canal. 
The  two  highest  nerves,  the  first  and  second  cervical, 
pursue  an  almost  horizontal  course  in  their  passage 
from  the  cord  to  their  points  of  exit  from  the  canal. 
The  remaining  nerves  take  a  more  and  more  oblique 
direction,  until  at  last  the  lowest  nerve  trunks  run 
nearly  vertically  downwards  as  they  pass  to  their 
respective  intervertebral  fonunina. 

Points  of  exit. — The  first  cervical  nerve  leaves  the 
canal  above  the  first  cervical  vertebra.  The  remaining 
cervical  trunks  escape  also  above  the  vertebra  after 
which  they  are  named,  the  eighth  cervical  nerve  leaving 
the  canal  between  the  last  cervical  and  the  first  dorsal 
vertebrae.  The  dorsal,  lumbar,  and  sacral  nerves  have 
their  points  of  exit  below  the  vertebrae  after  which  they 
are  named.  Thus,  the  first  dorsal  nerve  will  pass 
through  the  foramen  between  the  first  and  second 
dorsal  vertebras,  and  so  on. 


556*  SURGICAL  APPLIED  ANATOMY,  [cw  xxiv. 


Points  of  Origin  from  the  Cord. 

The   first  cervical  nerve  arises  from  the   cord   opposite   the 

interval  between  the  atlas  and  occiput. 
The   second  and  third  cervical  nerves  arise  from  the   cord 

opposite  the  axis. 
The  fourth,  fifth,  sixth,  seventh,  and  eighth  cervical  nerves 

arise  from  the  cord  opposite  the  third,  fourth,  fifth,  sixth, 

and  seventh  vertebra?  respectively. 
The  first  four  dorsal  nerves  arise  from  the  cord  opposite  the 

discs  below  the  seventh  cervical  and  the  first,  second,  and 

third  dorsal  vertebra  respectively. 
The  fifth  and  sixth  dorsal  nerves  arise  from  the  cord  opposite 

the  lower  borders  of  the  fourth  and  filth  vertebrae. 
The  remaining  six  dorsal  nerves  arise  from  the  cord  opposite 

the  bodies  of  the  sixth,  seventh,  eighth,  ninth,  tenth,  and 

eleventh  vertebrae. 
The  first  three  lumbar  nerves  arise  from  the  cord  opposite  the 

twelfth  dorsal  vertebra. 
The  fourth  lumbar  nerve  arises  from  the  cord  opposite  the  disc 

between  the  twelfth  dorsal  and  first  lumbar  vertebra?. 
The  last  lumbar  nerve,  together  with  the  sacral  and  coccygeal 

nerves,   arise    from   the   cord   opposite   the    first   lumbar 

vertebra. 

It  will  be  seen,  therefore,  that  in  taking  note  of 
the  symptoms  due  to  crushing  the  entire  nerve  con- 
tents of  the  vertebral  canal  at  a  certain  spot,  con- 
sideration must  be  taken,  not  only  of  the  effects  of 
damaging  the  medulla  at  that  point,  but  also  of  the 
result  of  lacerating  nerve  trunks  that  may  issue  there, 
although  their  origins  are  above  the  seat  of  lesion. 
The  cord  is  also  very  often  only  damaged  in  part,  or 
it  may  entirely  escape,  while  one  or  more  nerves  are 
crushed  by  the  fractured  vertebrae,  or  by  fragments  of 
bone  separated  by  the  lesion. 

In  fracture-dislocations  the  upper  vertebral  body, 
as  already  stated,  usually  glides  forwards,  with  the 
result  that  the  anterior  and  antero-lateral  parts  of  the 
cord  are  brought  into  violent  contact  with  the  pro- 
tecting border  of  the  vertebrae  below  the  seat  of  lesion. 


chap,  xxiv.j  THE  Spiffs.  557 

It  is  in  these  parts  of  the  cord  that  the  main  motor 
tracts  run,  and  thus  it  happens  that  motion  is  more 
often  lost  in  the  parts  below  the  site  of  the  injury 
than  is  sensation.  If  there  be  partial  motor  and 
sensory  paralysis,  the  disturbance  of  the  former 
function  is  likely  to  be  in  excess  of  that  of  the  latter. 
In  no  case,  indeed,  does  there  appear  to  have  been  a 
loss  of  sensation  without,  at  the  same  time,  some 
disturbance  in  the  powers  of  movement.  If  the  grey 
matter  of  the  cord  be  not  severely  damaged,  reflex 
movements  appertaining  to  that  segment  of  the  cord 
can  usually  be  induced  in  the  paralysed  parts  by 
proper  stimulation.  If  those  reflex  movements  be 
lost,  it  may  be  inferred  that  the  grey  matter  is  broken 
up,  and  that  the  entire  spinal  medulla  has  been 
crushed  at  the  seat  of  lesion. 

The  higher  up  the  fracture  in  the  column  the 
greater  is  the  tendency  for  the  function  of  respiration 
to  be  interfered  with.  If  the  lesion  be  at  the  upper  end 
of  the  dorsal  spine,  then  not  only  will  all  the 
abdominal  muscles  be  paralysed,  but  also  all  the  inter- 
costals.  A  fracture,  associated  with  injury  to  the 
cord,  when  above  the  fourth  cervical  vertebra,  is,  as  a 
rule,  instantaneously  fatal.  The  phrenic  nerve  comes 
off  mainly  from  the  fourth  cervical  nerve,  receiving 
contributions  also  from  the  third  and  fifth.  The 
fourth  nerve  issues  just  above  the  fourth  cervical 
vertebra.  If  the  cord  be  damaged  immediately  below 
this  spot,  the  patient  can  breathe  only  by  means  of 
the  diaphragm,  and  if  the  lesion  be  so  high  as  to 
destroy  the  main  contribution  to  the  phrenic,  respi- 
ration of  any  kind  becomes  impossible. 

Certain  disturbances  of  the  act  of  micturition  are 
frequent  in  cases  of  injury  to  the  cord.  The  reflex 
centre  for  this  act  is  lodged  in  the  lumbar  enlarge- 
ment The  irritation  of  the  vesical  walls,  produced 
by  the  increasing  distension  of  the  bladder,  provides 


558  SURGICAL  APPLIED  ANATOMY.  [Chap.  xxiv. 

the  needful  sensory  impulse.  This  impulse  is  re- 
flected to  the  nerves  controlling  the  bladder  muscles, 
and  especially  to  the  detrusor  urinae,  and  by  their 
contraction  the  organ  is  emptied.  The  action,  how- 
ever, can  be  to  some  extent  inhibited  by  influences 
passing  down  from  the  brain  to  the  lumbar  centre, 
and  the  tendency  to  a  frequent  discharge  of  urine 
is  resisted  by  contraction  of  the  sphincter.  When, 
therefore,  any  part  of  the  cord  is  damaged  that  lies 
between  the  lumbar  centre  and  the  brain,  this  inhibi- 
tion can  have  no  effect.  Immediately  after  the 
accident  the  temporary  suspension  of  reflex  actions 
from  shock  produces  some  retention  of  urine,  and 
after  that  the  bladder  empties  itself  at  frequent 
>  intervals,  the  patient  being  unconscious  of  the  act, 
and  unable  to  influence  it 

If  the  centre  itself  be  damaged  in  the  lumbar  cord, 
the  patient,  after  a  little  retention,  will  suffer  from 
absolute  incontinence  ;  and  a  like  result  will  follow  if 
the  nerve  connections  between  the  cord  and  bladder 
below  the  spinal  centre  have  been  destroyed.  The 
principal  nerves  connecting  the  medulla  spinalis  with 
the  bladder  are  the  third  and  fourth  sacral. 

The  act  of  defsecation  also  is  apt  to  be  disturbed 
in  a  like  manner.  Here  there  is,  as  in  the  previous 
case,  a  reflex  centre  in  the  lumbar  enlargement,  with 
motor  and  sensory  nerves  connecting  it  below  with 
the  rectum  and  its  muscles  ;  and  also  between  this 
centre  and  the  brain  are  tracts,  but  little  known, 
along  which  inhibitory  actions  can  extend. 

When  the  centre  itself  is  damaged,  or  the  con- 
nection severed  that  unites  it  with  the  viscus,  the 
patient  will  suffer  from  incontinence  of  faeces,  and 
will  be  unable  in  any  way  to  control  the  act.  When 
the  cord  is  damaged  at  any  spot  between  the  centre 
and  the  brain,  then  the  act  of  defsecation  will  be 
performed  at  regular  intervals,  without  either  the 


Chap,  xxiv.]  THE  SPINE.  559 

patient  being  conscious  of  the  act  or  being  capable  of 
inhibiting  it. 

In  some  injuries  to  the  cervical  cord  the  patient 
has  suffered  from  severe  vomiting  for  some  time  after 
the  accident,  or  has  exhibited  a  remarkable  alteration 
in  the  action  of  his  heart.  Mr.  Erichsen,  for  example, 
reports  the  case  of  a  man  who,  after  a  severe  blow 
upon  the  cervical  spine,  continued  to  vomit  daily  for 
several  months.  In  the  other  category,  instances 
have  been  recorded  when  the  pulse  has  sunk  as  low 
as  48,  or  even  as  36,  and  20,  after  lesions  to  the 
column  in  the  neck. 

These  changes  are  supposed  to  be  due  to  dis- 
turbance of  the  vagus,  and  it  is  further  suggested 
that  the  morbid  influence  is  conveyed  to  the  vagus  by 
the  spinal  accessory  nerve  with  which  it  is  so  freely 
associated. 

It  should  be  remembered  that  the  spinal  accessory 
trunk  has  origin  from  the  cord  as  low  down  as  the 
sixth  or  seventh  cervical  nerves. 

Operations  upon  the  cord.  —  Mr.  Victor 
Horsley  and  others  have  cut  down  upon  the  spine  and 
removed  a  tumour  from  the  spinal  cord  with  perfect 
success,  and  with  relief  to  the  symptoms  from  which 
the  patient  was  suffering.  The  spinal  canal  has  also 
been  exposed  in  certain  cases  where  callus  in  an  old 
fracture  of  the  spine  was  pressing  upon  the  cord,  or 
where  a  small  osseous  growth  was  encroaching  on  the 
sanal. 


INDEX. 


Ab.lomen,    Blood-vessels  of,  290, 
370 

,  Blows  on  the,  292 

,  Congenital    deformities    of 

the,  302 

,  Fascia  of.  291,  316 

,  Nerves  of,  298,  368 

— ,  Parietes  of,  287,  290,  296,  316 

• ,  Skin  of  the,  290 

,  Surface  anatomy  of  the,  287 

,  Wounds  of  the,  297 

"Abdominal  belt,"  291 

• connective    tissue    and    ab- 
scesses, 296 

Abscess,  Alveolar,  117 

,  Axillary,  208 

,  Cervical,  147 

,  Gluteal,  427 

,  Hepatic,  354 

,  Iliac,  317,  318 

in  antrum,  96 

in  mastoid  cells,  78 

in  testis,  411 

in   the   abdominal   parietes, 

297,  317 

in  the  scalp,  6 

in  the  temporal  fossa,  8 

,  Intercostal,  176 

,  Ischio-rcctal,  386 

,  Lumbar,  321 

,  Mammary,  177 

,  Mediastinal,  147,  184 

,  Orbital,  44 

,  Palmar,  269 

,  Parotid,  105 

,  Pelvic,  382, 441 

,  Perinephritic,  361 

,  Perityphlitic,  342 

,  Plantar,  511 

,  Popliteal,  474 

,  Post-pharyngei\l,  133 

,  Prostatic,  401 

,  Psoas,  319,  321,  433 

,  Renal,  364 

,  Thecal,  272 

Accelerator  nrinse,  385 

K  K — 4 


Acetabulum,  440 

,  Fractures  of,  375 

Acromio-clavicular  joint,  200 

— ,  Dislocations  of,  201 

-thoracic  artery,  190 

Acroniion  process,  Fracture  of, 
20:5 

Addison's  disease,  369 

Adductor  longus  muscle,  433,  437 

Air  in  veins,  166,  209 

"  Alderman's  nerve,"  74 

Alexis  St.  Martin's  case,  330 

Alveolar  abscess,  117 

Amputation.  (Sec  Arm,  Amputa- 
tion of,  etc.) 

Anal  triangle,  383 

Anastomotica  magna,  470,  472 

Aneurism,  Aortic,  165,  370 

,  Axillary,  2C9 

in  the  uer-k,  164 

of  the  posterior  tibial  artery, 

498 

,  Popliteal,  476 

Ankle.  505,  508 

,  Fascice  of,  510 

joint,  505,  517 

,  Amputation  at,  531 

,  Disease  of,  517 

— — ,  Dislocations  at,  518 

,  Fractures  about,  521 

,  Surface  anatomy  of,  505 

,  Tendons  of,  510.  513 

Annular  ligaments  of  ankle,  512 

of  wrist,  270,  272 

Anterior  crural  nerve,  431,  438, 448, 
538 

Antrum  of  Highmore,  91,  96 

of  mastoid,  78 

Anus,  383,  386,  420 

Aorta,  Abdominal,  289,  373 

,  Thoracic,  162,  165,  182 

Aortic  orifice,  182 

Aponouroses.     (See  Fasciae.) 

Appendix  vermiformis,  343 

Aqueous  humour,  60 

Arachnoid,  31,  551 


SURGICAL  APPLIED  ANATOMY. 


Arcus  senilis,  50 
Arm,  226 

,  Amputation  of,  233 

,  Fascia  of,  228 

,  Skin  of,  228 

,  Surface  anatomy  of,  226 

Arnold's  nerve,  74 

Arteries.     (See  Axillary,  etc.,  and 

Blood-vessels.) 
Arteriotomy,  12 
Arterio-venous  aneurisms,  45, 

239,  437 
Astragalus,  Dislocations  of,  525 

,  Fractures  of,  532 

Atlas,  133 

Atlo-axial  portion  of  spine,  544 

Auditory  ineatns,  External,  70 

,  its  relations,  73 

Auricle.     (See  Ear.) 
Auricles,  Supernumerary,  69 
Auriculo-veutricular  orifices,  183 
Axilla,  189,  205 

, ,  Suspensory  ligament  of,  206 

Axillary  abscess,  208 

artery,  189,  209 

fascise,  206 

glands,  189,  208 

nerves,  211 

vein,  209 

Axis,  133 
Azygos  veins,  184 

Barbadoes  leg,  440 

Bas-3  of  skull,  Fractures  of,  25 

Basilic  vein,  235,  236,  237,  2J8 

Bend  of  elbow,  231 

Bent  arm  after  venesection,  239 

Biceps  tendon  in  arm,  214 

in  ham,  475 

Bile  duct,  Rupture  of  the,  361 
Bladder,  392, 422 

,  Distension  of,  393 

,  Double,  398 

,  Extroversion  of.  303 

,  Fasciculated,  398 

,  Female,  399 

,  Foreign  bodies  in,  399 

found  in  hernise,  394 

,  Male,  392 

,  Mucous  membrane   of   the, 

397 

of  child,  400 

,  Puncture  of,  above  pubes,  395 

, ,  per  rectum,  396 

,  relations  to  the  peritoneujn, 

395 

• ,  Rupture  of  the,  396 

• ,  Sacculated,  398 

« stabbed  through  buttock,  432    i 


Blood-vessels    of   abdomen,    290, 

370 

of  abdominal  walls,  297 

of  auditory  meatus,  73 

of  brain,  39 

of  breast,  178 

of  buttock,  426,  429 

— • of  foot,  507,  514 

of  globe,  45,  50 

of  hand,  264,  273 

of  heel,  535 

of  knee,  472 

of  leg,  495,  498 

of  nares,  93 

of  neck,  164 

of  orbit,  45 

— •  of  palate,  129,  131 

of  pelvis,  382 

of  perineum,  386 

of  pinna.  73 

of  rectum,  420 

of  scalp,  11 

of  Scarpa's  triangle.  433. 

437 

of  spermatic  cord,  412 

of  tympanum,  83 

Brachial  artery,  229,  235,  2)0 

in  phlebotomy,  239 

,  Ligature  of,  229 

fascia,  228 

plexus,  141,  151,  282,  283,  431 

Brachialis  anticus,  229 
Brain,  33,  38 

and  skull  relations,  33 

Blood-vessels  of  the,  39 

Concussion  of  the,  33 

Convolutions  of,  35 

Cortex  of,  37 

Fissures  of,  35 

injuries,  32 

Membranes  of,  29 

Motor  centres  of,  37 

Sulci  of,  35 

Branchial  fistula!,  70,  168 
Brasdor's  operation,  164 
Breast,  177.     (S^e  Mamma.) 

— ,  Abscess  of,  177 
Bregma,  15 
Bronchi,  152,  158,  163 

— ,  Foreign  bodies  in,  15H 
Bronchocele,  159 
Brunner'e  glands  in  burns,  339 
Bryant's  method  of  dividing  the 
muscles  of  the  palate,  131 

triangle,  425 

Buccal  cavity,  119 

in  embryo,  128 

Bunions,  513 

Bursfe  about  the  elbow,  2il 


INDEX, 


563 


Burses  about  the  foot,  512 
—  about  the  liam,  477 

about  the  shoulder,  211,  214 

over  the   great   trocbanter, 

429 
oter  the  ischial  tuberosity, 

429 

over  the  knee-joint,  473 

,  Patellar,  473 

,  Subacromial,  211,  214 

Buttocks,  424 

^— ,  Arteries  and  nerves  of  the, 

426,  429 

,  Fascia  of,  427 

,  Fold  of,  425 

,  Surface  anatomy  of,  424 

CeBCum,  341,  352 

,  Foreign  bodies  in,  343 

,  Hernia  of,  342 

,  in  intestinal  obstruction,  312 

,  opening  of.  352 

,  Position  of,  341 

Cffisuriou  section,  376 
Calcaneo-astrtigaloid  joint,  524 

cuboid  articulation,  527 

scaphoid  ligament,  506,  527, 

530 

Canal  of  Muck,  Hernia  in,  311 
Cancrum  oris,  98 
Capsule  of  Teiion,  42 
Cardiac  orifice  of  stomncli,  327 
Carotid  artery,   78,  134,   136,  139, 

147,  164,  183 

,  Aneurism  of,  164 

— — destroyed   by   abscess, 

147 

,  Ligature  of,  164 

,  Wounds  of,  150 

tubercle,  139,  165 

Castration,  413 

Cataract,  59 

Catheterism  of  Eustachian  tube, 

82 

of  urethra,  403 

Centre  of  gravity  of  an  adult  body, 

374 

Cephalhtematomata,  7 
Cephalic  vein,  233,  237 
Cerebral  localisation,  37 
Cerebro-spinal  fluid,  32,  551 
Cervical.     (Sec  Neck.) 

sympathetic,  Paralysis  of,  48 

Cervico-dorsal  part  of  spine,  514 
Charbon,  98 
Cheek,  97,  98 
Cholecystectomy,  357 
Cholccjstenterostomy,  357 
Cholecystotomy,  357 


Chopart's  operation,  535 
Choroid,  50 
Ciliary  zone,  54, 55 
Circumcision,  407 
Circumcorneal  zone,  54 
Circumflex  artery,  external,  Bup- 

ture  of,  464 
,     internal,    Wound    of. 

464 

,  Posterior,  190,  212 

nerve,  190,  212 

Cirsoid  aneurism,  12 
Clavicle,  184, 186, 190 
—  ,  Dislocations  of,  199,  201 

,  Excision  of,  192 

,  Fractures  of,  193 

,  Movements  of,  197 

,  Ossification  of,  196 

,  Relations  of,  191, 196 

Cleft  palate,  127 
Clergyman's  sore-throat,  153 
Club-foot,  511,  527 
Coccygeus,  379,  380 
Coccygodyuia,  379 
Cochin  leg,  440 
Cceliac  axis,  290 
Colectomy,  352 
Colles'  fascia,  387 

fracture,  276 

Coloboina  iridis,  53 
Colon,  343 
— ,  Ascending,  346 

,  Descending,  346 

,  Malformation  of,  3i5,  317 

,  Operations  on,  349 

,  Stricture  of,  345 

,  Transverse,  346 

Colotomy,  Iliac,  351 

,  Lumbar,  349 

Compression  of  brain,  29 

of  cord,  551,  553 

Concussion  of  brain,  38 

of  cord,  552 

Congenital  club-foot,  511 

exomphalos,  303 

fistulas,  70,  168 

hernia,  307,  309,  310 

hydrocele,  308 

malformations  of    anus  and 

rectum,  421 

of  bladder,  303 

of  colon,  348 

of  penis,  408 

tumour    of    sterno-mastoicl. 

143 

Conjunctiva,  67 
Contre-coup,  Fracture  by,  25 
Convolutions    of    brain,     Motor 

centres  on,  37 


5^4 


SURGICAL  APPLIED  ANATOMY. 


Convolutions  of  brain,  Relations 
of,  33 

,  Relations  of,  to  skull,  33 

Coraco-acromial  arch,  213 

Coracoid  process,  Fracture  of,  203 

Cord,  Spinal,  549 

, ,  Concussion  of,  552 

, ,  Contusion  of,  553 

— — , ,  injuries  to  the,  Symp- 
toms of,  555 

Cornea,  48 

Coronal  suture,  15,  235 

Coronoid  process,  249 

Corpus  striatum,  35 

Coryza,  88 

Coup  de  fouet,  493 

Cowper's  duct,  415 

Craniectomy,  28 

Cranio-tabes,  15 

Cranium,  Bony  vault  of,  15 

Cremaster  muscle,  413 

Creniasteric  artery,  413 
-Cretinism,  160 

Cribriform  plate,  86 

Cricoid  cartilage,  139,  152 

Crico-thyroid  space,  139,  157 

Crutch  paralysis,  231 

Cuboid  bone,  506 

Cuneiform  bone,  Inner,  506 

• , ,  Dislocation  of  the, 

532 

, ,    Fracture  of  the, 

532 

Curves  of  the  vertebral  column, 
541 

Cut  throat,  149 

Cyphosis,  542 


Dartos,  291,  409 

Deltoid  muscle,  211,  213,  227 

• region,  186,  211 

tubercle,  186 

Diploic  veins,  13 

Dislocation.  (Seethe  several  bones 

and  joints.) 

Dorsal  vein  of  penis,  388 
Dorsalis  pedis  artery,  515 

—  scapulse  artery,  190 
Dorso-lumbar  part  of  spine,  541 
Drop-wrist,  283 
Duodenal  fossa,  338 
Duodenum,  358 

,  Suspensory  muscle  of,  338 

Dupuytren's  contraction,  268 

fracture,  521 

Dura  mater,  29,  550 

,  Fungus  of,  31 

Dysphonia  clericoruni,  153 


Ear,  69 

,  Bleeding  from,   in  fractures 

of  base  of  skull.  26 
— ,  Blood  supply  of,  73 

• coughing,  74 

,  External,  69 

,  Frost  bite  of,  74 

,  Gangrene  of,  74 

,  Hnematomata  of,  74 

,  Nerves  of,  74 

,  Polypi  of,  72 

sneezing,  74 

— — ,  Tophi  in,  70 

•,  Watery  discharge  from,  24. 

25 

yawning,  74 

Elbow,  234,  237 
— ,  Bursoe  about,  232 

,  Dislocations  of  the,  243 

,  Fold  of  the,  234 

,  Fractures  about,  246 

joint,  2iO 

,  Disease  of,  242 

,  Sprains  of,  242,  246 

— ,  Resection  of  the,  250 

— ,  Surface  anatomy  of  the,  23t 

,  Veins  about,  237 

Elephantiasis  Arabum,   409,   415, 

439 

Emissary  veins  of  s.kull,  13 
Encephalocele,  18 
Encysted  hydrocele  of  the  cord, 

308 

Euterectomy,  340 
Enteroraphy,  341 
Enterotomy,  340 

Epiphysis,  Lower,  of  feniur  in  ex- 
cision of  knee,  492 

, , in  knock-knee,  486 

of  acromion,   Separation  of, 

203 
of   clavicle,    Separation    of, 

196 

of  coracoid  process,  203 

of  femur,  Separation  of,  444 

452,  490 
of  hmnerus,    Separation   of, 

224,  248 

•  of  olecrauon,  249 

of  pelvis,  Separation  of,  373 

of  radius,  Separation  of,  249, 

279 
of  tibia,  Separation  of,   402, 

502 
of  third  phalanx  in  whitlow, 

272 

—  of  upper  limb,  286 
Epipteric  bone,  20 
Epispadiu,  408 


INDEX. 


565 


Epistaxis,  94 

Estlander's  operation,  176 
Eustachian  catheter,  To  pass,  82 

tube,  80 

Excision.     (See  special  parts.) 
External  auditory  meatus,  70 
Extravasation  of  urine,  291,  388 
Eye-ball,  48 

,  Blood  supply  of  the,  53 

,  Dangerous  area  of,  57 

,  Nerves  of  the,  55 

Eyelids,  64 


Face,  97 

,  Injuries  to,  99 

,  Nerves  of,  100 

,  Vessels  of,  98 

Facial  nerve,  107 

Fascia,  Abdominal,  291,  316 

,  Axillary,  206 

,  Bicipital,  239 

,  Cervical,  142 

,  Clavi-pectoral,  206 

,  Iliac,  316 

lata,  428,  435,  463 

lumborum,  321.  349 

• ,  Obturator,  381 

of  arm,  228 

of  buttock,  427 

of  Colles,  387 

of  deltoid  region,  211 

of  foot,  507,  510 

of  leg,  496 

of  palm,  266,263 

of  scalp,  1,  2,  6,  7 

of  Scarpa's  triangle,  435,  436 

of  thigh,  428,  435,  463 

Orbital,  42 

Palmar,  268 

Parotid,  104 

f  ectoral,  206 

Pelvic,  276 

Perinea!,  387 

Popliteal,  474 

Prevertebral,  146 

Recto-vesical,  381 

Temporal,  7 

Transversalis,  316 
l-'iis.'M-ulated  bladder,  398 
Fifth  Nerve,  Division  of,  103 
Femoral  hernia,  312 

vessels,  434,  437,  4C4 

Femur,  Dislocations  of,  453 

,  Fractures  of,  428,  449,  465 

Fenestra  ovalis,  77 

rotunda,  7S 

Ferguson's   method    of   dividing 
the  muscles  of  the  pal&te,  130 


Fibula,  409,  49 I,  495 

— ,  Fractures,  of,  500,  502 
Fissure  of  Rolando,  35 

of  Sylvius,  33,  35 

Fissures  of  brain,  Relations  of, 

33 
Fistula  at  the  navel,  295 

between  the  gall  bladder  and 

gut,  317 

,  Congenital,  69,  168 

,  Gastric,  330 

in  ano,  386 

,  Lachrymal,  68 

,  Salivary,  109 

,  Vesico-vaginal,  415 

Flat-foot,  503,  521 
Fold,  Gluteal,  417 
Fontanelle,  Sagittal,  19 

,  Temporary  occipital,  18 

Fontanelles,  14 
Foot,  Abscess  of,  511 

,  Amputations  of,  534 

,  Arches  of,  523 

- — ,  Blood-vessels  of,  507,  514 

,  Chief  joints  of,  524 

,  Dislocations  of,  525,  532 

,  Fasciae  of,  510 

— ,  Fractures  of,  531 

,  Integuments  of,  509 

,  Lymphatics  of,  516 

,  Nerves  of,  509 

— ,  Surface  anatomy  of,  505 

,  Synovia!  membranes  of,  531, 

533 

— ,  The,  £05,  508,  523 
Foramen  caecum  of  tongue,  1£0 

of  Majendie,  32 

of  Monro,  33  . 

Fore-arm,  251 

,  Amputation  of  the,  257 

,  Bones  of  the,  253 

,  Fractures  of  the,  255 

,  Luxations  of  the,  243 

,   Surface    anatomy   of    the, 

251 

— ,  Vessels  of  the,  252 
Fossa  duodeuo-jejunalis,  338 

,  Ischio-rectal,  383,  385 

,  Nasal,  86 

of  Rosenmuller,  82 

,  Subclavicular,  188 

Fracture.  (See  the  several  bones.) 

,  dislocation  of  the  vertebral 

column,  5i7 

,  Helicoide,  466,  502 

Fnenum  linguae,  122 
Frontal  sinus>,  95 
Funsrus  of  the  dura  mater,  31 
of  the  testicle,  412 


566 


SURGICAL  APPLIED  ANATOMY. 


Gall  bladder,  356 

,  Fundus  of,  353 

• ,  Operations  on,  357 

,  Bupture  of  the,  356 

stones,  346,  356 

Gangrene  of  nose,  85 

of  pinna,  74 

of  the  leg  and  embolism,  499 

Gasserian    ganglion    affected    by 

abscess  spreading  from  parotid, 

106 

,  Bemoval  of,  103 

Gastrocnemius  muscle,  495 

,  Bupture  of  the,  497 

Gastro-enterostomy,  334 
Gastrostomy,  3^9 
Gastrotomy,  329 
Generative  organs,  Female,  414 

,  Male,  407 

Geuito-crural  nerve,  412,  438 
Genu-valgum,  484 
Gladiolus,  171 
.Glaus  penis,  407 
Glaucoma,  51,  62 
Glottis,  152,  153 
GluteaJ  abscess,  427 
- — —  aneurisms,  429 

artery,  418,  426,  429 

bursae,  429 

fascia,  427 

fold,  425 

region,  424 

Gluteus  maxim  us,  428 

,  Rupture  of,  420 

Goitre,  159 

Groin,  Begion  of,  432 

Gullet.     (See  (Esophagus.) 

Gum&,  121 

Gustatory  nerve,  Moore's  u*ethod 

of  dividing  the,  121 

Hsematomuta  of  scalp,  6 

on  septum  iiasi,  92 

on  the  pinna,  74 

Hoematuria  after  injury  to  back, 

358 

Hajmoptysis,  180 
Haemorrhage  from  chorokl,  51,  55 

from  frsenum  linguee,  122 

from  intercostal  vessel  •*,  175 

from  tongue,  123 

from  tonsil,  136 

in  lithotomy,  389,  391 

into  vitreous,  55 

in  tracheotomy,  156,  157 

meuing-eal,  30 

Hseniorrhoidal  vessels  and  nerves, 

386,  420 
Hsemothorax,  180 


Hamstring  muscles,  462,  474 
Hand,  261,  264,  265 

,  Amputation  of,  231 

• — — ,  Blood-vessels  and'lymphatics 

Of,  264,  273 

,  Dislocations  of,  279,  280 

,  Fascise  of,  266,  268 

,  Surface  anatomy  of,  261 

,  Synovial  sheaths  of,  271 

Hang-ing,  Mode   of  death   from. 

554 

Hard  Palate,  129 
Hare-lip,  128 
Heart,  Ih2 
,  its  relation  to  the  surface, 

182 

,  Valves  of,  183 

— ,  Wounds  of,  183 
Heel,  Blood-vessels  of,  535 

,  Integuments  of,  535 

Helicoidal  fractures  of    Leriche, 

466,  502 
Hernia,  Congenital,  307,  309,  310 

,  Diaphragmatic,  316 

,  Direct,  305 

,  Encysted,  309 

,  Femoral,  312 

,  Infantile,  309 

,  Inguinal,  303,  310 

into  the   funicular    process, 

309 

,  Lumbar,  315 

,  Mesenteric,  337 

,  Obturator,  314 

,  Omental,  321 

,  Perineal,  315 

,  Pudendal,  315 

,  Bare  forms  of,  315 

,  Betro-peritoneal,  337 

,  Sciatic,  315 

,  Umbilical,  293,  303,  315 

,  Vaginal,  415 

Herniotomy,  311,  314 
Hip,  Dislocations  t>f,  453 

joint,  440 

• ,  Amputation  at  the,  459 

disease,  442,  451 

,  Fractures  al>out,  419 

,  Movements  of,  441 

,  Begion  of  the,  424 

Hippoeratic  hand,  267 
Holdeu's  line,  432 
Hottentot  Venus,  427 
Human  tails,  379 
Humerus,  Dislocations  of,  217 

,  Fractures  of,  223,  229,  216 

,  — — ,  Non-union  after,  232 

Hydatid  cyst  in  the  liver,  356 
Hydrencephalocele,  17 


INDEX, 


567 


Hydrocele,  308,  411 

of  the  neck,  169 

Hydrocephalus,  15,  33 
Hyoid  boue,  138, 151 

,  Accessory  glands  about, 

160 

,  Fracture  of,  151 

Hypertrophy  of  the  prostate,  401 
Hypopyon,  61 
Hypospadias,  408 
Hypothenar  eminence,  261 
Hysterical  hip,  448 
knee,  448 

Ichthyosis  linguae,  123 
Ileo-csecal  intussusception,  344 

= —  region,  341 

valve,  344 

colic  intussusception,  344 

Tli 'in n.     (See  Intestine,  small.) 
Iliac  abscess,  317,  318 

colotomy,  331 

fascia,  317 

Ilio-psoas  muscle,  317,  436 

tibial  band,  428,  463,  469 

Indirect  hernia,  305 
Inequality  of  limbs  in  length,  466 
Infantile  hernia,  309 
Inferior   dental   nerve,  Dividing 
the,  102 

maxilla,  Dislocations  of,  114 

,  Excision  of,  115 

,  Fracture  of,  112 

thyroid  veins,  138,  149,  186 

Iiifraorbital  foramen,  101 
Inguinal  canal,  303,  311 

colotomy,  351 

hernia,  303,  311 

Innominate  artery,  157, 164, 163, 183 

bone,  372 

Intercostal  artery,  176 

spaces,  175 

Internal  mammary  artery,  175 
luterparietal  bone,  19 
Intervertebral  discs,  542 
Intestine,  Foreign  bodies  in,  3t_>, 
343 

,  Large,  344 

,  Operations  on,  319 

,  Stricture  of,  345 

Resection  of,  351 

Small,  331 

,  Diverticula,  337 

,  Injury  of,  336 

— ,  Length  of,  33 1 
— ,  Operations  on,  3tO 

,  Position  of,  335 

Intussusception,  344 
Inversion  of  the  testicle,  411 


Iridectomy,  53 

Iris,  50 

Iritis,  52 

Ischio-rectal  abscess,  386 

fossa,  379,  383,  385 

Isthmus  of  the  thyroid,  157 
,  Division  of,  157, 159 

Jacob's  ulcer  of  the  eyelid,  64 
Jaws.    (See  Inferior  and  Superior 

Maxilla.) 

Jejunum.     (See  Intestine,  small.) 
Joints,  Surgical  classification  of 

the,  213 
Jugular  vein,  78, 134, 136, 139, 119 

Keloid,  its  frequent  seat,  171 
Kidney,  361 

,  Abnormalities  of,  365 

,  Abscess  of,  364 

,  Hilus  of,  362,366 

— ,  Horse-shoe,  366 
,  its  relations,  362 

— ,  Movable,  365 

,  Operations  on,  366 

,  Rupture  of.  362 

vessels,  Point  of   origin  of, 

290 
Knee,  Blood  supply  of  the,  472 

• ,  Bursse  about,  469,  473,  477 

,  DUlocations  of  the,  489 

— ,  Fractures  about,  486,  490 

,  Integuments  of,  471 

joint,  479 

,    Amputation    through, 

494 

,  Disease  of,  481 

,  Excision  of  the,  492 

,  Region  of,  468 

,  Surface  anatomy  of  the,  -168 

Knock-knee,  484 

Labia  majora,  414 
Labyrinth  of  enr,  83 
Lachrymal  abscess,  68 

apparatus,  68 

gland,  68 

sac,  68 

Lacuna  magna,  Urethral,  406 
Lambda,  15 
Lambdoid  suture,  15 
Lamina  cribrosa,  51,  64 

fusca,  51 

snprachoroidea,  51 

Laparotomy,  340 
Laryngotomy,  154,  157 
Larynx,  138,  150 

,  Excision  of,  153 

,  Foreign  bodies  in,  158 


568 


SURGICAL  APPLIED  ANATOMY. 


Larynx,  Fracture  of,  152 

,  Mucous  membrane  of,  153 

Lateral  lithotomy,  388 
Leg,  494 

,  Amputation  of,  505 

,  Fascise  of,  496 

•,  Fractures  of,  500 

,  Rickets  affecting  bones  of, 

503 

,  Skin  of,  496 

,  Surface  anatomy  of,  491 

,  Vessels  of,  495,  498 

Lens,  58 

Levator  ani,  380,  386 

,   relation   to  fistula    in 

ano,  386 

palati,  130 

paljiebrse,  65 

Ligauientum  patellffi,  469,  481,  488 

pectinatum  iridis,  CO 

Lighterman's  bottom,  429 
Linea  alba,  288,  293 

semilunaris,  288 

Lingual  artery,  40 

— —  tonsil,  126 

Lipomata  in  deltoid  region,  211 

in  neck,  142 

in  Scarpa's  triangle,  435 

on  the  buttock,  427 

rare  on  face,  98 

Lips,  118 

Lisfranc's  amputation,  536 

Lithotomy,  Lateral,  388 

, ,  in  children,  390 

, ,  Parts  divided  in,  3S9 

• ,  Median,  390 

, versus  lateral,  391 

— ,  Suprapubic,  392 
Littre"s  operation,  348 
Liver,  352 

,  Abscesses  of,  352 

in  pyseruia,  352 

,  Protrusion  of,  351 

,  Relations  of,  350 

,  Kuptures  of,  353 

,  Wounds  of,  353 

Lockjaw,  117 

Lordosis  in  hip  disease,  4ti 
Loreta's  operation,  334 
Lower  limb,  Length  of,  466 

,  Lymphatics  of,  439 

,  Nerve  supply  of,  537 

Lukasmic     enlargement    of     the 

spleen,  360 
Lumbar  colectomy,  351 

—  colotomy,  349 

fascia,  321 

hernia,  316 

region,  320 


Lumbar  spine,  542 

,  Injuries  to,  543,  546,  548, 

558 
Lung,  178 

and  secondary  deposits,  180 

cavities,  Drainage  of,  182 

,  Hernia  of,  148,  180 

in  neck,  148,  178 

,  Relations  of  to  surface,  178 

,  Rupture  of,  180 

,  Wounds  of  180 

Luschka's  tonsil,  82,  133 
Lymphangioraa  cavernosum,  125 
Lymphatic   glands   and    vessels 

(Sec  each  region.) 

Macro-glossia,  125 

Malar  bone,  103 

,  Fracture  of,  103 

Malleoli,  505 

,  Fr.ictures  of,  in  dislocations 

of  the  foot,  519 

Mamma,  176 

,  Arteries  of,  178 

in  groin,  435 

,  Lymphatics  of,  178 

,  Nerves  of,  178 

Mammary  abscess,  177 

Manubrium,  171 

Mastication,  Muscles  of,  117 

Mastoid  autrum,  78 

cells,  78 

,  Perforation  of,  89 

Maxillte.     (See  Inferior  and  Supe- 
rior.) 

Meatus,  Tbe  auditory,  70 

Meatuses  of  nose,  90 

Meckel's  diverticuluin,  293,  337 

ganglion,  101 

Median  lithotomy,  390 

nerve,  230,  253,  285,  431 

Mediastina,  185 

,  Abscess  of,  147,  185 

Medio-tarsal  joint,  506,  527 
,  Amputation  at,  535 

Meibomian  glands,  65 

Melanotic  growths  of  choroid,  5' 

Membrana  tympani,  76 

Membranous  urethra,  402 

Meuiugeal  artery,  9,  30 

haemorrhage,  30 

Meninges  of  brain,  29 

of  spinal  cord,  550 

Meningitis  from  abscess  in    the 
ear,  73,  78,  80,  89 

(spinal)      from     bed-sores, 

545 

Moiiingocele,  17,  86,  89 

Meseuteric  arteries,  290,  370 


INDEX. 


569 


Mesenteric  hernia,  3 'J9 

—  boles,  324 
Mesentery,  824 

,  Length  of,  325 

— — ,  Prolapse  of,  326 
Meso-colic  hernia,  3tO 
colon,  316,  347 

—  -nephron,  365 
Metacarpo-phalangeal     joint     of 

thumb,  Dislocations  at,  280 
Metatarsal  bone  of  great  toe,  Am- 
putation of,  538 

—  bones,  Fractures  of  the,  532 
lletatarso  -  phalangeal     articula- 
tions, 506 

joint  of  great  toe,  Dis- 
location at,  533 

Miner's  elbow,  241 

Motor  centres  on  the  cortex,  37 

paralysis  in  injuries  to  cord, 

557 

Mouth,  118 

Mucous  polyp  of  nose,  92 

Mumps,  107 

Muscee  volitantes,  62 

Mtisculo-spiral  nerve,  230,  233 

Myzoeduma,  160 

Noil,  267 

Nares,  Anterior,  86 
— ,  Posterior,  87 
Nasal  bones,  86 

,  Fracture  of,  86 

cavity,  86 

,  Blood-vessels  of,  93 

,  Nerve  supply  of,  94 

douche,  89 

fossse,  86 

mucous  memhrane,  91 

polypus.  87,  92 

Neck,  137 

Abscess  of,  146 

Fasciae  of,  143 

Fistulas  of,  168 

Great  vessels  of,  139,  164 

Hydrocele  of,  169 

Integuments  of,  141 

Lung  in,  148, 177 

Lymphatic  glamis  of,  167 

Middle  line  of,  138 

Nerves  of,  140 

Ribs  in,  148 

Side  of,  139 

Surface  anatomy  of,  137 

Wounds  of,  149 
Nelaton's  line,  425 
Nephrectomy,  366 
Nephro-lithotomy,  366 
Nephroraphy,  3<Ki 


Nephrotomy,  366 
Nerve  stretching,  431 

supply  of  lower  limb,  537 

of  upper  limb,  282 

Nerves.     (See  various  regions.) 
,    Division   of.    (See   various 

trunks.) 
of    the   spinal   cord,    their 

po'nts  of  exit,  555 
Neuralgia,  Facial,  100 

of  scali>.  13 

Nipple,  177 

in  groin,  435 

Nose,  84 

,  Cartilaginous  port  of,  85 

Notch  of  Bivini,  76 

Obturator  hernia,  314 

nerve,  448.  538 

or  thyroid  dislocation,    453, 

458 
Occipital  bone  at  birth,  17 

,    Necrosis    of,     causing1 

wasting  of  tongue,  124 
(Edema  of  the  glottis,  153 
(Esophagostomy,  163 
CEsophagotomy,  163 
(Esophagus,  161 
— ,  Cancer  of,  163 

,  Foreign  bodies  in,  162 

,  Operations  on,  163 

,  Relations  of,  162 

Olecrauon,  236 

,  Fractures  of,  249 

Omega  loop  of  colon,  347 
Oineutal  hernia,  324 

sac,  324 

Ornentum,  Great,  323 
Ophthalmia,  Sympathetic,  58 
Optic  disc,  59 

neuritis,  60 

thalamus,  35 

Ora  serrata,  59 
Orbicularis-palpebrarum,  65 
Orbit,  41 

,  Abscess  of,  44 

,  Arteries  of,  45 

,  Dimensions  of,  41 

,  Fasciae  of,  42 

,  Fracture  of,  41 

,  Muscles  of,  45 

,  Nerves  of,  46 

,  Pulsating  tumours  of,  45 

,  Relations  of,  42 

Os  calcis,  Dislocations  of  the,  525 

,  Fractures  of  the,  531 

<5pactal,  18 

iucisivum  in  hare-lip,  128 

innominatum,  372,  375 


SUKGICAL  APPLIED  ANATOMY. 


Os  magnum,  Dislocation  of,  280 
Ovary,  416 

Paciniau  bodies  in  the  foot,  510 

in  the  hand,  265 

Palate.  127 

,  Cleft.  127 

,  Hard,  129 

,  Soft,  130 

Palmar.    (Sec  Hand.) 
Palmaris  longus  tendon,  259 
Pancreas,  360 
Pancreatic  cysts,  361 
Paracentesis  of  the  pericardium, 

181 

of  thorax.  174 

of  tympanum,  77 

of  ventricles  of  brain,  15 

Paralysis  in  spinal  injuries,  555, 

557 

of  anterior  crural  nerve,  301 

of  cervical  sympathetic,  48 

- of  external  popliteal  nerve, 

540 

of  great  sciatic  nerve,  540 

of  internal  popliteal   nerve, 

540 

of  median  nerve,  285 

of  musculo-spiral  nerve,  283 

of  obturator  nerve,  538 

of  orbital  nerves,  46 

of  uliiar  nerve,  285 

Parietal  fissures,  19 
Parieto-occipital  fissure,  36 
Parotid  abscess,  104 

fascia,  104 

gland,  104,  107 

region,  103 

tumour,  108 

Patella,  468,  478,  486 

,  Dislocation  of,  488 

,  Fractures  of,  486 

Patellar  ligament,  469,  481,  488 
Pelvic  arch,  372 

cellulitis,  382,  441 

fascia,  380 

symphysis,  376 

Pelvis,  372 

,  Floor  of,  3SO 

,  Fractures  of,  374 

,  Mechanism  of,  -'J72 

,  Nerves  of,  421 

,  Vessels  of,  382 

Penile  urethra,  405 
Penis,  407 

• -,  Malformations  of,  408 

Perforating  ulcer,  510 
Pericardium,  Tapping  of,  18i 
Pericranium,  5 


Perineal  hernia,  315 
Perinephritic  abscess,  361 
Perineum,  Depth  of,  385 

,  Fascise  of,  387 

•,  Male,  383 

,  Nerves  of,  421 

- — ,  Vessels  of,  386 
Peritoneum,  324 
Perityphlitis,  342 
Peroneal  artery,  495 

tubercle,  506 

Peroneus  tertius,  507 
Petit's  triangle,  289,  320 
Petro-squamous  suture,  7S 
Phantom  tumour,  293 
Pharynx,  131 

,  Foreign  bodies  in,  132 

,  Mucous  membrane  of,  133 

,  Relations  of,  133 

Photophobia,  57 

Phrenic  nerve,  141,  358 

Pigeon  breast,  170 

Piles,  420 

Pinna,  69.     (See  Ear.) 

Pirogoff's  amputation,  535 

Plantar.     (See  Foot.) 

Plantaris  tendon,  Kupture  of,  497 

Plaques  des  fumeurs,  123 

Plaiysma  myoides,  141 

Pleura,  179 

,  Wounds  of,  179,  180 

Pueumatocele,  80 

Pneutno-thorax,  179 

Politzer's  method  of  inflating  the 

middle  ear,  81 
Pollock's  method  of  dividing  the 

muscles  of  the  palate,  130 
Polypus  of  nose,  87,  92 
Popliteal  abscess,  474 

bursae,  477 

fascia,  474 

glands,  471,  477 

nerves,  431,  469,  471,  510 

space,  469,  473 

—  vessels,  469,  475,  495 
Post-nasal  growths,  92 
Pott's  disease  of  spine,  549 

,  Operations  in,  170,  549 

fracture,  521 

Profunda  arteries  in  arm,  227 

femoris,  434,  437 

Prolapsus  ani,  419 
Pronation,  Movement  of,  254 
Pronator  radii  teres,  234 
Prostate,  400,  417 

,  Abscess  of,  401 

,  Hypertrophy  of,  401 

Prostatectomy,  402 
Prostatic  plexus  of  veins,  402 


INDEX. 


Psoas  abscess,  31?,  320 

muscle,  317,  436 

Pterion,  14 
Ptosiei,  46 
Pubic  spine,  288 
Pudendal  hernia,  315,  415 
Pulmonary  apoplexy,  ISO 

artery,  182 

Punctft  lachrymalia,  68 
Pylorus,  327,  331 
— ,  Resection  of  the,  333 

Eadial  artery,  252,  261 

—  nerve,  Strength  of  the,  431 
Radius,  Dislocations  of  the,  244, 

245 
,  Fractures  of  the,  249,  254, 

256,27(5 
Eanula,  120 
Kectocele,  415 
Eecto- vaginal  fistula,  415 
Rectum,  416 

,  Attachments  of  the,  419 

,  Effects  of  distension  of,  418 

,  Foreign  bodies  in,  418 

of  infant,  417 

,  Introduction  of  hand  into, 

418 
- — ,  Mucous  membrane  of,  419 

,  Serous  membrane  of,  417 

,  Vessels  of,  420 

Rectus  abdominis  muscle,  295 
Resections.  (Seethe  various  parts.) 
Respiratiou   in   fracture   of   the 

spine,  557 
Retina,  59 

Retro-peritoneal  hernia,  339 
Rhinolithes  in  the  nose,  91 
Khinoplasty,  10,  228 
Rhinoscopy,  88 
Ribs,  172 

,  Cervical,  148 

,  Excision  of,  175 

,  Fractures  of,  173 

Rickets,  Effect  of,  on  pelvis,  373 

, ,  on  the  ribs,  174 

, ,  on  the  skull,  15 

, ,  on  tibia,  503 

Rider's  bone,  427 

sprains,  437 

Rima  glo-ttidis,  138 
Rosenmuller,  Fossa  of,  82 
Rouge's  operation,  87 

Sacro-coccygeal  joint,  379 

-iliac  synchondrosis,  376 

Sacrum,  372 

,  Dislocation  of  tha,  377 

Sagittal  fontanelle,  19 


Salivary  fistulas,  109 
Saphenous  opening,  434 

veins,  438,  462,  470,  499 

Sartorius  muscle,  433,  436,  458 
Scalene  muscles,  139, 142 
Scalp,  Abscess  of,  6 

,  Dangerous  area  of,  2 

,  Fatty  tissue  in,  2 

,  HeBmatoma  of,  7 

,  its  mobility,  3 

,  Nerves  of,  11 

,  Neuralgia  of,  14 

- — -,  Sebaceous  tumours  of,  2 

,  Sutures  in  wounds  of,  3 

,  Suppuration  in  the,  6 

,  Temporal  region  of,  7 

,  Vascularity  of  the,  4 

,  Vessels  of,  11 

wounds,  3 

Scaphoid  bone,  Dislocation  of  the, 

532 
Scapula,  188,  202 

,  Excision  of,  204 

,  Fractures  of,  203 

Scarpa's  triangle,  432 

,  Fascia  of,  435 

,  Glands  of,  438 

,  Vessels  of,  429,  434,  437 

Sciatic  artery,  421,  426 

dislocation,  453,  456 

nerve,  Great,  426,  430,  431, 

448,540 
Sciatica,  430 
Sclerotic,  50 

Scrofula,  Sign  of,  in  pinna,  70 
Scrofulous  pharyngitis,  133 
Scrotum,  408 

and  elephantiasis,  409 

and  oedema,  409 

,  Application  of  leeches  to  the, 

409 
,  Subcutaneous  tissue  of  the, 

409 
Semilunar    cartilages    of    knee, 

Dislocation  of  the,  483 
Seoiimembranosus  tendon,  470, 474 
Shoulder,  186 

,  Bursse  about,  211,  214 

,  Dislocations  of  the,  217 

,  Fractures  about  the,  223 

joint,  213 

,  Amputation  at  the,  225 

,  Disease  of  the,  215 

,  Surface  nnatomy  of,  185 

tip  pain  from  liver  ailments, 

370 

Sigaulteon  operation,  376 
Sigmoid  flexure,  348 
Sinuses  of  skull,  11,  30,  95 


572 


SURGICAL  APPLIED  ANATOMY. 


Skull,  14 

,  Abnormalities  of,  17 

,  Deformities  of,  16, 19 

,  Development  of,  16 

,  Emissary  veins  of,  12 

,  Fractures  of ,  20 

,  Necrosis  of,  5,  19 

of  infant,  16,  19,  20,  21,  22 

,  Soft  parts  covering,  1 

• •,  Sutures  of,  15,  28 

,  Tbickuess  of,  28 

,  Trephining  the,  9 

,  Venous  tumours  of,  14 

Soft  palate,  130 

Solar  plexus,  368 

Solens,  495 

Spermatic  artery,  412 

cord, 412 

plexns  of  veins,  412 

Sphincter  ani,  385,  420 

Spina  biflda,  378 

Spinal  accessory  nerve,  141 

cord,  545,  549 

— ,  Concussion  of,  552 

,  Contusion  and  crush- 
ing of,  553 

,  Loss  of  motion  due  to 

injury  of  the,  557 

, of  sensation  due  to 

injury  of  the,  557 

• ,  Operations  on,  559 

,  Wounds  of,  551 

injuries  and  defseeation,  558 

and  micturition,  558 

and  respiration,  557 

and  vomiting,  559 

meninges,  550 

meningitis,  551 

nerves,  Points  of  origin,  555 

Spine,  541 

,  Curves  of,  541 

,  Fractures  and  dislocations 

of,  544 

,  Sprains  of,  542 

,  Trephining  the,  549 

Spiuous  processes,  Fracture  of, 
548 

Splay  foot,  529 

Spleen,  357 

,  Capsule  of  the,  359 

,  Enlarged,  359 

,  Extirpation  of  the,  360 

,  Injuries  to  tl'e,  358 

— — ,  Relations  of,  357 

,  Rupture  of,  359 

Steuson's  duct,  108 

Sterno-clavicular  joint,  196 

,  Disease  of,  198 

,  Dislocations  of,  199 


Sterno  -  clavicular    joint,     Move- 
ments of,  197 

-mastoid  muscle,    139,     142, 

143,  145 

—  -xiphoid  joint,  171 

Sternum,  171 

,  Fractures  of,  171 

,  Holes  in,  172 

,  Separation  of  segments  of, 

172 

,  Trephining  the,  172 

Stomach,  327 

,  Fistulas  of,  330 

,  Foreign  bodies  in,  330 

,  Hernia  of,  335 

,  Operations  on,  331,  33! 

,  Relations  of,  327,  329 

,  Vertical,  329 

,  Wounds  of  the,  329 

Strabismus,  43,  45 

Siihacromial  bursa,  211 

Subarachnoid  space,  31,  551 

Subastragaloid  amputation,  537 

dislocations  of  the  foot.  526 

Subelaviau  artery,  140 

vein,  140 

Subclavicular  fossa,  188 

Subclavius  muscle,  191 

Subdural  space,  31,  551 

Sublingual  bursa  niucosa,  120 

Subserous   connective    tissue   of 
the  abdomen,  296 

Sulciof  brain,  Relations  of,  33 

Superior  maxilla,  110 

,  Cleft  of,  127 

,  Excision  of  the,  110 

,  Fractures  of,  109 

,  Necrosis  of,  109 

thyroid  artery,  139 

veua  cava,  181 

Supination,  Movement  of,  254 

Supinator  lon^us,  234 

Supraclavicular  nerves,  190 

Supraorbital  foramen,  101 

Suprapubic  lithotomy,  292 

Susteutaculum  tali,  505 

• • ,  Fracture  of,  531 

Sutures  of  skull,  15,  18,  20,  28 

,  Closure  of,  22 

.Relations  of,  to  brain, 

33 

, ,  to  surface,  14 

,  Separation  of,  28 

Sycosis,  65 

Symblepharon,  67 

Sympathetic  ophthalmia,  5S 

Syrnphysis  of  pelvis,  376 

Synostosis  of  skull,  if2 

Syuovial  cavities  of  the  foot,  533 


INDEX. 


573 


Synovial  sheaths  in  the  hand,  271 
Synovitis,  Acute,  in  the  hip-joint. 

442 
, ,  in  the  knee,  483 

Tabatiere  anatomique,  264 
Tagliacozzi's  operation,  228 
Talipes  calcaneus,  528 

cavils,  511 

equinus,  527 

and  the  plantar  fascia,  511 

— — ,  mixed  forms  of,  529 
—  valgus,  528 

varus,  528 

Tarsal  bones,  Fractures  and  dis- 
locations of,  531 

cartilage,  65 

cyst,  66 

Tarsectomy,  529 
Tarsus.     (See  Foot.) 
Taxis,  311 
Teeth,  116,  117 
Temporal  abscess,  8 
fascia,  7 

—  fossa, 7 
Temporo-maxillary     articulation, 

113 

,  Dislocations  at,  114 

Tendo  Achillis,  489,  507, 513 

—  oculi,  68 
Tenon's  capsule,  42 
Teuotomy  and  the  peroneal  nerve, 

475 
of  hamstrings,  475 

— -  of  sternp-mastoid,  143 
Tensor  palaii,  130 
Testicle,  410,  423 

,  Descent  of,  307 

,  Fungus  of,  412 

,  in  the  foetus,  305,  307 

,  Inversion  of,  411 

,  Investments  of,  413 

,  Tunic  of,  414 

Thecal  abscess,  272 
Thenar  eminence,  261 
Thigh,  461 

,  Amputation  of  the,  4G8 

,  Fasciae  of,  463 

,  Fractures  of,  4G5 

,  Integuments  of,  462 

,  Muscles  of,  463 

— ,  Surface  anatomy  of,  461 
Thoracic  duct,  185,  371 
Thoracoplasty,  176 
Thorax,  170 

,  Paracentesis  of,  174 

,  Viscera  of,  178 

,  Walis  of,  170 

Thun»l>,  Amputation  of  the,  282 


Thumb,  Dislocation  of,  280 

Thymus,  156 

Thyroid  body,  137,  138,  158 

,  Accessory  glands  of,  160 

,  Development  of,  160 

,  Excision  of,  160 

in  tracheotomy,  157 

cartilage,  138,  152 

Thyroidea  ima  artery,  156, 161 
Tibia    and    fibula,   Fractures    of, 

500 
— ,  Fractures  of,  491,  500,  502 

in  rickets,  503 

— ,  Shaft  of,  its  strength,  500 
Tibial  vessels-,  495,  498,  "499,  515 
Tibialis  anticus  muscle,  495 
Tongue,  122 
,  Accessory  glands  about,  125, 

160 

,  Dermoid  cyst  of,  125 

,  Blood  supply  of,  123 

,  Epithelium  of,  123 

— ,  Excision  of,  126 

,  Mucous  cysts  of,  123 

,  Nerve  supply  of,  124 

tie,  122 

Tonsil.  134 
— ,  Bleeding  from,  136 

,  Foreign  body  in,  136 

,  Hypertrophy  of,  135 

, ,  and  deafness,  135 

,  Lingual,  126 

,  Luschka's,  82, 133 

,  Pharyngeal,  82,  133 

Trachea,  138,  151,  154 

,  Foreign  bodies  in,  158,  182 

Tracheotomy,  154 
Transverse  cervical  artery,  110 

colon,  344 

process  of  the  atlas,  137 

of  cervical  vertebra,  137 

Trapezium,  264 

Trephining,  9,  549 

Triangular      ligament      of      the 

urethra,  380,  388 
Trigone,  397 
Trisnius,  117 
Tubcra  ischii,  372,  425 
Tunica  abdominals,  291 

albnginea,  411 

vaginalis,  307,  410 

Tympanum,  77 

Ulna,  Dislocation  of  the,  243 

,  Fracture  of  the,  255,  257 

Ulnar  artery,  252 

n-rve,  228,  240,  285,  433 

vein  in  venesection,  239 

Umbilical  fistula,  295 


SURGICAL  APPLIED  ANA  TOM'?. 


Umbilical  hernia,  293,  303 
Umbilicus,  Fibrous  ring  of,  293 

,  Position  of,  288 

,  Vessels  of,  294 

Umbo  of  membrana  tympani,  77 
Urachns,  293 
Ureters,  367 

and  regnrgitation    of   urine. 

399 

,  Distension  of,  363 

,  Rupture  of,  368 

Urethra,  Female,  407,  422 

,  Male,  402,  422 

, ,  Curve  of,  403 

,  Membranous,  403 

,  Mucous  membrane  of,  398 

,  Narrowest  parts  of,  407 

• ,  Penile,  402 

,  Prostatic,  402 

,  Eupture  of  the,  407 

Urethral  triangle,  383,  386 
Uterus,  416 

Vagina,  415 

Vaginal  cystocele,  415 

Valsalva's  method  of  inflating  the 

middle  ear,  81 
Varicocele,  414 
Varicose  veins,  414,  HB 
Vas  deferens,  412 
Veins.     (See  various  parts.) 

,  Air  in,  166,  209 

,  Emissary,  of  skull,  12 


Venesection  at  the  elbow,  238 

in  the  foot,  516 

on  the  arm,  238 

Venous  tumours  of  skull,  14 
Vermiform  appendix,  343 
Vertebra,  Caries  of,  321 

prominens,  137 

Vertebral  artery,  165, 166 

column,  533 

Vesico-vaginal  fistula,  415 
Vitello-intestinal  duct,  295,  ",37 
Vitreous  humour,  60,  62 
Volvulus  of  the  sigmoid  flexure, 

347 
Vulva,  414 

Wardrop's  operation,  164 
Weaver's  bottom,  429 
Wharton's  duct,  120 
White  line  at  anus,  420 

in  the  pelvic  fascia,  380 

Whitlow,  272 
Wormian  boues,  19 
Wrist,  259 

joint,  261,  274 

,  Amputations  at,  231 

,  Dislocations  at,  279 

,  Fractures  about,  276 

-,  Movements  at,  275 

,  Surface  anatomy  of  the,  259 

Wry  neck,  143 

Zygoma,  Fracture  of,  11 


Printed  by  CASSKI.L  &  COMPANY,  LIJIITKD,  La  Belle  Sauvage,  London,  E.C. 
'5-594 


Date  Due 


WO  101 
T  812s 


Dreves.      Surgical  applied  anatomy 


WO  101 
T     812s 


;ves.  Surgical  applied  anatomy 


CCM  LIBRARY 


